Provider Demographics
NPI:1225697758
Name:SMART, KATHLEEN ANNE (PTA)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:ANNE
Last Name:SMART
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1450 OLD POLK CITY RD
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33809-2381
Mailing Address - Country:US
Mailing Address - Phone:863-608-1321
Mailing Address - Fax:
Practice Address - Street 1:1919 LAKELAND HILLS BLVD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33805-2901
Practice Address - Country:US
Practice Address - Phone:863-688-5612
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-09
Last Update Date:2019-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant