MEDICARE: SPENCER K ISA DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	PT309156	CA

General Provider Information

NPI Number	:	1063382216
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SPENCER K ISA DPT

Provider Business Mailing Address
First Line	:	550 SAINT CHARLES DR STE 100
Second Line	:
City	:	THOUSAND OAKS
State	:	CA
Zip	:	91360-3969
Country	:	US
Telephone Number	:	805-777-1023
Fax Number	:	888-506-7977

Provider Business Practice Location Address
First Line	:	550 SAINT CHARLES DR STE 100
Second Line	:
City	:	THOUSAND OAKS
State	:	CA
Zip	:	91360-3969
Country	:	US
Telephone Number	:	805-777-1023
Fax Number	:	888-506-7977

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/11/2025
Last Update Date	:	11/11/2025

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