Provider Demographics
NPI:1144386848
Name:SMITH, TERESA L (PT)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:L
Last Name:SMITH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6313 S HAROLD AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33616-2612
Mailing Address - Country:US
Mailing Address - Phone:678-429-0912
Mailing Address - Fax:813-374-5893
Practice Address - Street 1:6313 S HAROLD AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33616-2612
Practice Address - Country:US
Practice Address - Phone:678-429-0912
Practice Address - Fax:813-374-5893
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2009-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA8737225100000X
FLPT 16583225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL884184500Medicaid
GA921750561AMedicaid
GA921750561BMedicaid