Provider Demographics
NPI:1164633350
Name:SMITH, GABRIEL AE (PT)
Entity Type:Individual
Prefix:
First Name:GABRIEL
Middle Name:AE
Last Name:SMITH
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3744 BEYER LN
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42001-4419
Mailing Address - Country:US
Mailing Address - Phone:270-519-1143
Mailing Address - Fax:
Practice Address - Street 1:4813 ALBEN BARKLEY DR
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42001-6774
Practice Address - Country:US
Practice Address - Phone:270-534-7278
Practice Address - Fax:270-534-7279
Is Sole Proprietor?:No
Enumeration Date:2007-05-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY004496225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist