Provider Demographics
NPI:1417525965
Name:SMITH, DEIDRA NICOLE (OTR)
Entity Type:Individual
Prefix:
First Name:DEIDRA
Middle Name:NICOLE
Last Name:SMITH
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5350 OLD DOWLEN RD APT 525
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77706-6632
Mailing Address - Country:US
Mailing Address - Phone:325-267-1463
Mailing Address - Fax:
Practice Address - Street 1:87 IH 10 N STE 225
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77707-2549
Practice Address - Country:US
Practice Address - Phone:409-835-0228
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-11
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist