Provider Demographics
NPI:1053473025
Name:GAMBLE-SMITH, SHERETTA L (OT)
Entity Type:Individual
Prefix:MRS
First Name:SHERETTA
Middle Name:L
Last Name:GAMBLE-SMITH
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:SHERETTA
Other - Middle Name:L
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1690 SHELBY DR
Mailing Address - Street 2:
Mailing Address - City:SOUTHSIDE
Mailing Address - State:AL
Mailing Address - Zip Code:35907-0628
Mailing Address - Country:US
Mailing Address - Phone:256-547-1387
Mailing Address - Fax:
Practice Address - Street 1:409 E 10TH ST
Practice Address - Street 2:
Practice Address - City:ANNISTON
Practice Address - State:AL
Practice Address - Zip Code:36207-4780
Practice Address - Country:US
Practice Address - Phone:256-238-0110
Practice Address - Fax:256-238-5143
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1650174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1650OtherOT LICENSE