Provider Demographics
NPI:1427384502
Name:SMITH, THERESA W (OTR/L,RN)
Entity Type:Individual
Prefix:MS
First Name:THERESA
Middle Name:W
Last Name:SMITH
Suffix:
Gender:F
Credentials:OTR/L,RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 NE 400 AVE
Mailing Address - Street 2:
Mailing Address - City:OLD TOWN
Mailing Address - State:FL
Mailing Address - Zip Code:32680-8328
Mailing Address - Country:US
Mailing Address - Phone:352-542-0757
Mailing Address - Fax:
Practice Address - Street 1:619 S MARION AVE
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-5808
Practice Address - Country:US
Practice Address - Phone:386-755-3016
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-26
Last Update Date:2012-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT9745225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist