Provider Demographics
NPI:1417201369
Name:SMITH, ZACHARY S (OTR)
Entity Type:Individual
Prefix:
First Name:ZACHARY
Middle Name:S
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 1:4608 CHURCH ST SW
Mailing Address - Street 2:
Mailing Address - City:SOUTH BOARDMAN
Mailing Address - State:MI
Mailing Address - Zip Code:49680-9762
Mailing Address - Country:US
Mailing Address - Phone:231-388-1544
Mailing Address - Fax:
Practice Address - Street 1:812 S GARFIELD AVE STE 1
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686-3456
Practice Address - Country:US
Practice Address - Phone:231-421-9201
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-30
Last Update Date:2019-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201008391225XN1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XN1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistNeurorehabilitation