=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629594767
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SPENCER SIMMONS DPT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/21/2017
-----------------------------------------------------
Last Update Date | 07/21/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 22 WOODCLIFF DR
-----------------------------------------------------
City | SIMSBURY
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06070-2837
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-670-7258
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 22 WOODCLIFF DR
-----------------------------------------------------
City | SIMSBURY
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06070-2837
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-670-7258
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 011639
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 042161
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------