Provider Demographics
NPI:1467786319
Name:SMITH, CHARISSA BETHE'L (ATC)
Entity Type:Individual
Prefix:
First Name:CHARISSA
Middle Name:BETHE'L
Last Name:SMITH
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:98 POPLAR ST
Mailing Address - Street 2:
Mailing Address - City:BLACKFOOT
Mailing Address - State:ID
Mailing Address - Zip Code:83221-1758
Mailing Address - Country:US
Mailing Address - Phone:208-785-3841
Mailing Address - Fax:
Practice Address - Street 1:1767 BLUE SKY DR
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402-4802
Practice Address - Country:US
Practice Address - Phone:208-525-7770
Practice Address - Fax:208-525-7778
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-24
Last Update Date:2018-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDAT-3862255A2300X
NV05062212255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer