Provider Demographics
NPI:1255506283
Name:SPENCER, BRIAN M (OT, CHT)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:M
Last Name:SPENCER
Suffix:
Gender:M
Credentials:OT, CHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1441 S BEVERLY GLEN BLVD
Mailing Address - Street 2:#213
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-6162
Mailing Address - Country:US
Mailing Address - Phone:714-654-1522
Mailing Address - Fax:
Practice Address - Street 1:8600 W 3RD ST
Practice Address - Street 2:SUITE 3B
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-3338
Practice Address - Country:US
Practice Address - Phone:310-275-2130
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-30
Last Update Date:2014-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT 2313225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABI447ZMedicare PIN