Provider Demographics
NPI:1417186370
Name:SMITH, ANGELA GRACE (DI)
Entity Type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:GRACE
Last Name:SMITH
Suffix:
Gender:F
Credentials:DI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6317 HIGHWAY 329
Mailing Address - Street 2:
Mailing Address - City:CRESTWOOD
Mailing Address - State:KY
Mailing Address - Zip Code:40014-9040
Mailing Address - Country:US
Mailing Address - Phone:502-384-0910
Mailing Address - Fax:502-384-0908
Practice Address - Street 1:6317 HIGHWAY 329
Practice Address - Street 2:
Practice Address - City:CRESTWOOD
Practice Address - State:KY
Practice Address - Zip Code:40014-9040
Practice Address - Country:US
Practice Address - Phone:502-384-0910
Practice Address - Fax:502-384-0908
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-13
Last Update Date:2014-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist