Provider Demographics
NPI:1043751852
Name:SMITH, MARY L (LPT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:L
Last Name:SMITH
Suffix:
Gender:F
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 CENTRAL AVE STE 3
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-1377
Mailing Address - Country:US
Mailing Address - Phone:307-634-0298
Mailing Address - Fax:307-634-0837
Practice Address - Street 1:4000 CENTRAL AVE STE 3
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-1377
Practice Address - Country:US
Practice Address - Phone:307-634-0298
Practice Address - Fax:307-634-0837
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-13
Last Update Date:2017-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY161111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedic