Provider Demographics
NPI:1134675325
Name:SMITH, RAEGAN MARREE (MS, LAT, ATC)
Entity Type:Individual
Prefix:MS
First Name:RAEGAN
Middle Name:MARREE
Last Name:SMITH
Suffix:
Gender:F
Credentials:MS, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2210 12TH AVE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31707-3251
Mailing Address - Country:US
Mailing Address - Phone:812-340-1554
Mailing Address - Fax:
Practice Address - Street 1:2210 12TH AVE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31707-3251
Practice Address - Country:US
Practice Address - Phone:812-340-1554
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-29
Last Update Date:2021-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
IN2255A2300X390200000X
GAAT0037372255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program