Provider Demographics
NPI:1497911580
Name:SMITH, ZOE LEA (PT)
Entity Type:Individual
Prefix:MISS
First Name:ZOE
Middle Name:LEA
Last Name:SMITH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:ZOE
Other - Middle Name:LEA
Other - Last Name:WALLS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:1071 THOMAS AVE
Mailing Address - Street 2:
Mailing Address - City:WATKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30677-6073
Mailing Address - Country:US
Mailing Address - Phone:770-207-6390
Mailing Address - Fax:678-374-4855
Practice Address - Street 1:348 BIG A RD
Practice Address - Street 2:
Practice Address - City:TOCCOA
Practice Address - State:GA
Practice Address - Zip Code:30577-6003
Practice Address - Country:US
Practice Address - Phone:770-207-6390
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-29
Last Update Date:2020-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT009342225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA925273895BMedicaid