Provider Demographics
NPI:1124534391
Name:SMITH, ERIC ROBERT (LMBT)
Entity Type:Individual
Prefix:MR
First Name:ERIC
Middle Name:ROBERT
Last Name:SMITH
Suffix:
Gender:M
Credentials:LMBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6633 HARTLAND ST
Mailing Address - Street 2:
Mailing Address - City:NAVARRE
Mailing Address - State:FL
Mailing Address - Zip Code:32566-8103
Mailing Address - Country:US
Mailing Address - Phone:850-542-9594
Mailing Address - Fax:
Practice Address - Street 1:1752 SEA LARK LN
Practice Address - Street 2:
Practice Address - City:NAVARRE
Practice Address - State:FL
Practice Address - Zip Code:32566-7406
Practice Address - Country:US
Practice Address - Phone:850-542-9594
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-22
Last Update Date:2017-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL72094225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist