Provider Demographics
NPI:1174198402
Name:SMIDDY, KILEY
Entity Type:Individual
Prefix:
First Name:KILEY
Middle Name:
Last Name:SMIDDY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42 WINTER ST STE 25
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE
Mailing Address - State:MA
Mailing Address - Zip Code:02359-4958
Mailing Address - Country:US
Mailing Address - Phone:781-335-6663
Mailing Address - Fax:
Practice Address - Street 1:42 WINTER ST STE 25
Practice Address - Street 2:
Practice Address - City:PEMBROKE
Practice Address - State:MA
Practice Address - Zip Code:02359-4958
Practice Address - Country:US
Practice Address - Phone:781-335-6663
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-20
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA13559225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist