Healthcare Provider Details

I. General information

NPI: 1699516179
Provider Name (Legal Business Name): SPENCER KELLEN GONZALEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2024
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 US 50
MILFORD OH
45150-9510
US

IV. Provider business mailing address

255 HILLCREST DR
CINCINNATI OH
45215-2609
US

V. Phone/Fax

Practice location:
  • Phone: 513-346-8947
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT007365
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: