Provider Demographics
NPI:1164203949
Name:SMITH, GLENISE S (LMT)
Entity Type:Individual
Prefix:
First Name:GLENISE
Middle Name:S
Last Name:SMITH
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:229 GREAT EAST NECK RD
Mailing Address - Street 2:
Mailing Address - City:WEST BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11704-7801
Mailing Address - Country:US
Mailing Address - Phone:631-833-0499
Mailing Address - Fax:
Practice Address - Street 1:229 GREAT EAST NECK RD
Practice Address - Street 2:
Practice Address - City:WEST BABYLON
Practice Address - State:NY
Practice Address - Zip Code:11704-7801
Practice Address - Country:US
Practice Address - Phone:631-833-0499
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-09
Last Update Date:2023-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019026225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist