Basic Information
| Provider Information | |||||||||
| NPI: | 1427384502 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | THERESA | ||||||||
| MiddleName: | W | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | OTR/L,RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 110 NE 400 AVE | ||||||||
| Address2: | |||||||||
| City: | OLD TOWN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326808328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3525420757 | ||||||||
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| Practice Location | |||||||||
| Address1: | 619 S MARION AVE | ||||||||
| Address2: | |||||||||
| City: | LAKE CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320255808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3867553016 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2009 | ||||||||
| LastUpdateDate: | 07/31/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | OT9745 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.