Provider Demographics
NPI:1487184214
Name:SMITH, MARY CULBERTSON
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:CULBERTSON
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:ELIZABETH
Other - Last Name:CULBERTSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2695 ELMS PLANTATION BLVD STE C
Mailing Address - Street 2:
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29406-7132
Mailing Address - Country:US
Mailing Address - Phone:843-974-4097
Mailing Address - Fax:
Practice Address - Street 1:440 OLD TROLLEY RD STE D
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29485-5685
Practice Address - Country:US
Practice Address - Phone:843-871-3522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCPT8652225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PT8652OtherSC STATE LICENSING BOARD