Provider Demographics
NPI:1407431547
Name:SMITH, CAROLYN MICHELLE (DPT)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:MICHELLE
Last Name:SMITH
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 HERITAGE MILL DR UNIT 206
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32084-7532
Mailing Address - Country:US
Mailing Address - Phone:904-502-8724
Mailing Address - Fax:
Practice Address - Street 1:720 SAINT JOHNS BLUFF RD N
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32225-6704
Practice Address - Country:US
Practice Address - Phone:904-646-1144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-10
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT36952225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist