Basic Information
| Provider Information | |||||||||
| NPI: | 1710645957 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SPENCER | ||||||||
| FirstName: | TERRY | ||||||||
| MiddleName: | WAYNE | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | LPTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 204E. 3RD , BOX 153 | ||||||||
| Address2: | |||||||||
| City: | HOFFMAN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62250 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6187803490 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2600 COMPASS ROAD | ||||||||
| Address2: | |||||||||
| City: | GLENVIEW | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8777873430 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2021 | ||||||||
| LastUpdateDate: | 12/06/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant | 225200000X | 160.004322 | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.