Provider Demographics
NPI:1174193411
Name:SMITH, REBECCA SUE (OTR, CLT)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:SUE
Last Name:SMITH
Suffix:
Gender:F
Credentials:OTR, CLT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 COPLEN RD
Mailing Address - Street 2:
Mailing Address - City:MAYFIELD
Mailing Address - State:KY
Mailing Address - Zip Code:42066-6428
Mailing Address - Country:US
Mailing Address - Phone:903-216-8177
Mailing Address - Fax:
Practice Address - Street 1:1253 LAKE BARKLEY DR
Practice Address - Street 2:
Practice Address - City:KUTTAWA
Practice Address - State:KY
Practice Address - Zip Code:42055-6124
Practice Address - Country:US
Practice Address - Phone:270-388-2291
Practice Address - Fax:270-388-0948
Is Sole Proprietor?:No
Enumeration Date:2021-06-29
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY265527225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist