Provider Demographics
NPI:1508425521
Name:SMITH, EMILY MICHELLE (COTA)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:MICHELLE
Last Name:SMITH
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 FM 3414
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:TX
Mailing Address - Zip Code:75951-7863
Mailing Address - Country:US
Mailing Address - Phone:409-383-3102
Mailing Address - Fax:
Practice Address - Street 1:2333 MANOR DR
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77802-1907
Practice Address - Country:US
Practice Address - Phone:409-383-3102
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-12
Last Update Date:2019-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX215747224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant