Provider Demographics
NPI:1578293221
Name:SMITH, CAITLYN (ATC)
Entity Type:Individual
Prefix:
First Name:CAITLYN
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1644 KIRKLAND DR
Mailing Address - Street 2:
Mailing Address - City:SUNNYVALE
Mailing Address - State:CA
Mailing Address - Zip Code:94087-5701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3500 MOUNTAIN BLVD
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94619-1699
Practice Address - Country:US
Practice Address - Phone:408-420-0190
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-15
Last Update Date:2022-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
2000051791OtherBOARD OF CARTIFICATION