Provider Demographics
NPI:1508917543
Name:SMITH, KENNETH C (PT)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:C
Last Name:SMITH
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2665 SNEED RD
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62902-0443
Mailing Address - Country:US
Mailing Address - Phone:618-964-1647
Mailing Address - Fax:
Practice Address - Street 1:3307 BROADWAY ST
Practice Address - Street 2:SUITE 140
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-2347
Practice Address - Country:US
Practice Address - Phone:618-244-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist