Provider Demographics
NPI:1073094678
Name:SMITH, SARA SMITH
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:SMITH
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 KIMBERLY LN
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75604-1314
Mailing Address - Country:US
Mailing Address - Phone:903-578-0586
Mailing Address - Fax:
Practice Address - Street 1:2530 GREENHILL RD
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:TX
Practice Address - Zip Code:75455-6744
Practice Address - Country:US
Practice Address - Phone:903-572-0974
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-22
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX214626224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant