Provider Demographics
NPI:1437114832
Name:SMITH, EDITH G (PT)
Entity Type:Individual
Prefix:
First Name:EDITH
Middle Name:G
Last Name:SMITH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1805 BANCROFT ST
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-5781
Mailing Address - Country:US
Mailing Address - Phone:406-543-4890
Mailing Address - Fax:406-543-4892
Practice Address - Street 1:1805 BANCROFT ST
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-5781
Practice Address - Country:US
Practice Address - Phone:406-543-4890
Practice Address - Fax:406-543-4892
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2007-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT218PT225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0347072Medicaid