Provider Demographics
NPI:1225208796
Name:SMITH, TANYA
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:
Last Name:SMITH
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 1:20702 EL TORO RD
Mailing Address - Street 2:#272
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630-6127
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1717 W ORANGEWOOD AVE
Practice Address - Street 2:SUITE I
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-2040
Practice Address - Country:US
Practice Address - Phone:714-712-8346
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-11
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner