Provider Demographics
NPI:1508406364
Name:SMITH, CLARE CAROLINE (ATC)
Entity Type:Individual
Prefix:MS
First Name:CLARE
Middle Name:CAROLINE
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:PO BOX 5302
Mailing Address - Street 2:
Mailing Address - City:HAUPPAUGE
Mailing Address - State:NY
Mailing Address - Zip Code:11788-0306
Mailing Address - Country:US
Mailing Address - Phone:631-300-0209
Mailing Address - Fax:
Practice Address - Street 1:50 VANDERBILT PKWY
Practice Address - Street 2:
Practice Address - City:DIX HILLS
Practice Address - State:NY
Practice Address - Zip Code:11746-5816
Practice Address - Country:US
Practice Address - Phone:631-300-0209
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-09
Last Update Date:2020-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003472-12255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer