Provider Demographics
NPI:1376879130
Name:SMITH, STEPHEN D (PT, DPT, SCS, CSCS)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:D
Last Name:SMITH
Suffix:
Gender:M
Credentials:PT, DPT, SCS, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 GULF BREEZE PKWY
Mailing Address - Street 2:
Mailing Address - City:GULF BREEZE
Mailing Address - State:FL
Mailing Address - Zip Code:32561-4838
Mailing Address - Country:US
Mailing Address - Phone:850-916-8650
Mailing Address - Fax:
Practice Address - Street 1:6355 WILLOWFIELD WAY
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:VA
Practice Address - Zip Code:22150-1038
Practice Address - Country:US
Practice Address - Phone:623-308-4573
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2020-09-22
Deactivation Date:2009-09-25
Deactivation Code:
Reactivation Date:2009-10-28
Provider Licenses
StateLicense IDTaxonomies
FL234512251S0007X
DCPT8720712251S0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports