Provider Demographics
NPI:1285184010
Name:SMITH, NATHAN DALE (MS,OTR/L)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:DALE
Last Name:SMITH
Suffix:
Gender:M
Credentials:MS,OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2940 FAUBUSH RD
Mailing Address - Street 2:
Mailing Address - City:NANCY
Mailing Address - State:KY
Mailing Address - Zip Code:42544-6577
Mailing Address - Country:US
Mailing Address - Phone:859-481-4055
Mailing Address - Fax:
Practice Address - Street 1:105 CITATION DR STE B
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:KY
Practice Address - Zip Code:40422-8633
Practice Address - Country:US
Practice Address - Phone:859-236-2193
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-05
Last Update Date:2016-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYR-3677225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist