Provider Demographics
NPI:1083861256
Name:SMITH, TASHA KENAE (OTR/L)
Entity Type:Individual
Prefix:MISS
First Name:TASHA
Middle Name:KENAE
Last Name:SMITH
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 S 10TH ST
Mailing Address - Street 2:
Mailing Address - City:MASCOUTAH
Mailing Address - State:IL
Mailing Address - Zip Code:62258-1736
Mailing Address - Country:US
Mailing Address - Phone:618-566-8000
Mailing Address - Fax:618-566-7408
Practice Address - Street 1:201 S 10TH ST
Practice Address - Street 2:
Practice Address - City:MASCOUTAH
Practice Address - State:IL
Practice Address - Zip Code:62258-1736
Practice Address - Country:US
Practice Address - Phone:618-566-8000
Practice Address - Fax:618-566-7408
Is Sole Proprietor?:No
Enumeration Date:2008-08-19
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.006822225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist