Provider Demographics
NPI:1376777177
Name:SMITH, GERTRUD (LMT)
Entity Type:Individual
Prefix:
First Name:GERTRUD
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1615 COLONIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-1101
Mailing Address - Country:US
Mailing Address - Phone:239-274-8201
Mailing Address - Fax:239-275-6558
Practice Address - Street 1:1615 COLONIAL BLVD
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-1101
Practice Address - Country:US
Practice Address - Phone:239-274-8201
Practice Address - Fax:239-275-6558
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-07
Last Update Date:2009-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA 41056225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist