Provider Demographics
NPI:1164129714
Name:SMITH, SEAN DOUGLAS (DPT)
Entity Type:Individual
Prefix:
First Name:SEAN
Middle Name:DOUGLAS
Last Name:SMITH
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2122 YORK RD STE 300
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-1925
Mailing Address - Country:US
Mailing Address - Phone:570-550-0168
Mailing Address - Fax:410-648-4878
Practice Address - Street 1:222 EAST MAIN ST
Practice Address - Street 2:STORE #17
Practice Address - City:COLLEGEVILLE
Practice Address - State:PA
Practice Address - Zip Code:19426-2650
Practice Address - Country:US
Practice Address - Phone:610-601-0641
Practice Address - Fax:610-601-0642
Is Sole Proprietor?:No
Enumeration Date:2023-02-14
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT031079225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist