Provider Demographics
NPI:1538347323
Name:SMITH, TINA NICOLE (PTA, LMT, NCTMB)
Entity type:Individual
Prefix:MRS
First Name:TINA
Middle Name:NICOLE
Last Name:SMITH
Suffix:
Gender:F
Credentials:PTA, LMT, NCTMB
Other - Prefix:MRS
Other - First Name:NIKKI
Other - Middle Name:
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PTA, LMT, NCTMB
Mailing Address - Street 1:505 BRIARWOOD DR
Mailing Address - Street 2:L8
Mailing Address - City:ENTERPRISE
Mailing Address - State:AL
Mailing Address - Zip Code:36330-5029
Mailing Address - Country:US
Mailing Address - Phone:334-341-4514
Mailing Address - Fax:
Practice Address - Street 1:505 BRIARWOOD DR
Practice Address - Street 2:L8
Practice Address - City:ENTERPRISE
Practice Address - State:AL
Practice Address - Zip Code:36330-5029
Practice Address - Country:US
Practice Address - Phone:344-255-7169
Practice Address - Fax:334-255-7173
Is Sole Proprietor?:No
Enumeration Date:2008-02-05
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL23837225200000X
OH33.010538225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist