Provider Demographics
NPI:1558471144
Name:SMILEY, SARA J (PT)
Entity Type:Individual
Prefix:MS
First Name:SARA
Middle Name:J
Last Name:SMILEY
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 1:2129 GENERAL BOOTH BLVD
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23454-5872
Mailing Address - Country:US
Mailing Address - Phone:757-430-8828
Mailing Address - Fax:
Practice Address - Street 1:2129 GENERAL BOOTH BLVD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23454-5872
Practice Address - Country:US
Practice Address - Phone:757-430-8828
Practice Address - Fax:757-430-8189
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2008-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2314225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40269600Medicaid
WI40269600Medicaid
WI001083450Medicare ID - Type Unspecified