Provider Demographics
NPI:1518197631
Name:SMITH, CLARISSA (PT)
Entity Type:Individual
Prefix:MS
First Name:CLARISSA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3480 CAPITAL AVENUE SW
Mailing Address - Street 2:
Mailing Address - City:BATTLE CREEK
Mailing Address - State:MI
Mailing Address - Zip Code:49015
Mailing Address - Country:US
Mailing Address - Phone:269-979-3000
Mailing Address - Fax:269-979-9790
Practice Address - Street 1:3480 CAPITAL AVENUE SW
Practice Address - Street 2:
Practice Address - City:BATTLE CREEK
Practice Address - State:MI
Practice Address - Zip Code:49015
Practice Address - Country:US
Practice Address - Phone:269-979-3000
Practice Address - Fax:269-979-9770
Is Sole Proprietor?:No
Enumeration Date:2009-07-23
Last Update Date:2009-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501007288225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0A35702OtherBLUE CROSS BLUE SHIELD OF MICHIGAN
MI0A35702OtherBLUE CROSS BLUE SHIELD OF MICHIGAN