Provider Demographics
NPI:1407244551
Name:SMITH, MARK VERNON (OTR)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:VERNON
Last Name:SMITH
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15506 APPLEWOOD LN
Mailing Address - Street 2:
Mailing Address - City:KEARNEY
Mailing Address - State:MO
Mailing Address - Zip Code:64060-8820
Mailing Address - Country:US
Mailing Address - Phone:816-628-6502
Mailing Address - Fax:
Practice Address - Street 1:15506 APPLEWOOD LN
Practice Address - Street 2:
Practice Address - City:KEARNEY
Practice Address - State:MO
Practice Address - Zip Code:64060-8820
Practice Address - Country:US
Practice Address - Phone:816-628-6502
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-23
Last Update Date:2014-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO003519225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist