Provider Demographics
NPI:1013407915
Name:SMITHBACK, ALEX N (D-PT)
Entity Type:Individual
Prefix:
First Name:ALEX
Middle Name:N
Last Name:SMITHBACK
Suffix:
Gender:M
Credentials:D-PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 22487
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-2487
Mailing Address - Country:US
Mailing Address - Phone:920-445-7222
Mailing Address - Fax:920-445-7289
Practice Address - Street 1:311 N 3RD AVE
Practice Address - Street 2:
Practice Address - City:STURGEON BAY
Practice Address - State:WI
Practice Address - Zip Code:54235-2401
Practice Address - Country:US
Practice Address - Phone:920-743-0255
Practice Address - Fax:920-743-6680
Is Sole Proprietor?:No
Enumeration Date:2018-05-16
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14166-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist