Healthcare Provider Details

I. General information

NPI: 1952764128
Provider Name (Legal Business Name): SPENCER WILLIAMSON LAT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2016
Last Update Date: 03/19/2022
Certification Date: 04/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1032 W VAUGHN ST
TEMPE AZ
85283-5446
US

IV. Provider business mailing address

7750 ZIONSVILLE RD STE 800
INDIANAPOLIS IN
46268-5128
US

V. Phone/Fax

Practice location:
  • Phone: 480-226-2224
  • Fax: 844-261-5625
Mailing address:
  • Phone: 317-536-4870
  • Fax: 844-261-5625

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1425
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: