Provider Demographics
NPI:1073892394
Name:SMITH, TASHA LYNNE (PTA)
Entity Type:Individual
Prefix:MISS
First Name:TASHA
Middle Name:LYNNE
Last Name:SMITH
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 BRANDYWINE BLVD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-1500
Mailing Address - Country:US
Mailing Address - Phone:770-461-2928
Mailing Address - Fax:
Practice Address - Street 1:110 BRANDYWINE BLVD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-1500
Practice Address - Country:US
Practice Address - Phone:770-461-2928
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-04
Last Update Date:2011-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPTA002747225200000X
DEJ20000289225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant