Provider Demographics
NPI:1457670754
Name:SMOTHERS, REBECCA M (PTA)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:M
Last Name:SMOTHERS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1510 BYRUM RD
Mailing Address - Street 2:
Mailing Address - City:BLYTHEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72315-8033
Mailing Address - Country:US
Mailing Address - Phone:870-532-2600
Mailing Address - Fax:
Practice Address - Street 1:1510 BYRUM RD
Practice Address - Street 2:
Practice Address - City:BLYTHEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72315-8033
Practice Address - Country:US
Practice Address - Phone:870-532-2600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-26
Last Update Date:2010-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2179225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR161010724Medicaid