Provider Demographics
NPI:1407332208
Name:SMITH, TRISTA LASHAUN (COTA)
Entity Type:Individual
Prefix:MS
First Name:TRISTA
Middle Name:LASHAUN
Last Name:SMITH
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 JUDY LN
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-8659
Mailing Address - Country:US
Mailing Address - Phone:318-613-2674
Mailing Address - Fax:
Practice Address - Street 1:419 S COCKRELL HILL RD
Practice Address - Street 2:
Practice Address - City:DUNCANVILLE
Practice Address - State:TX
Practice Address - Zip Code:75116-4939
Practice Address - Country:US
Practice Address - Phone:972-708-8801
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-15
Last Update Date:2018-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX210715224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant