Provider Demographics
NPI:1275938458
Name:POLK SMITH, CHRISTIE M (LCOTA)
Entity Type:Individual
Prefix:
First Name:CHRISTIE
Middle Name:M
Last Name:POLK SMITH
Suffix:
Gender:F
Credentials:LCOTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 309
Mailing Address - Street 2:
Mailing Address - City:CALHOUN
Mailing Address - State:LA
Mailing Address - Zip Code:71225-0309
Mailing Address - Country:US
Mailing Address - Phone:318-331-3862
Mailing Address - Fax:
Practice Address - Street 1:516 LECKIE RD
Practice Address - Street 2:
Practice Address - City:CALHOUN
Practice Address - State:LA
Practice Address - Zip Code:71225-9085
Practice Address - Country:US
Practice Address - Phone:318-331-3862
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-29
Last Update Date:2014-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAOTA.200421224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant