Provider Demographics
NPI:1033194154
Name:SMITH, KRISTINE KAY (MS, ATC)
Entity Type:Individual
Prefix:MS
First Name:KRISTINE
Middle Name:KAY
Last Name:SMITH
Suffix:
Gender:F
Credentials:MS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4926 HEATHER DR
Mailing Address - Street 2:APT 112
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-4134
Mailing Address - Country:US
Mailing Address - Phone:847-636-9215
Mailing Address - Fax:
Practice Address - Street 1:261 MACK AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2417
Practice Address - Country:US
Practice Address - Phone:313-745-1160
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-12
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer