Basic Information
| Provider Information | |||||||||
| NPI: | 1598896730 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SPENCER | ||||||||
| FirstName: | RYAN | ||||||||
| MiddleName: | MATTHEW | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | M.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 262 N LOS ROBLES AVE APT 121 | ||||||||
| Address2: | |||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911011534 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3232579600 | ||||||||
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| Practice Location | |||||||||
| Address1: | 840 N AVENUE 66 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900421508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3232579600 | ||||||||
| FaxNumber: | 3232578118 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | IMF52358 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.