Provider Demographics
NPI:1598840084
Name:SMITH, RICHARD K (CTRS,WOSH)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:K
Last Name:SMITH
Suffix:
Gender:M
Credentials:CTRS,WOSH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1139 HUNTINGTON DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91030-4516
Mailing Address - Country:US
Mailing Address - Phone:310-478-3711
Mailing Address - Fax:310-268-3279
Practice Address - Street 1:1139 HUNTINGTON DR
Practice Address - Street 2:
Practice Address - City:SOUTH PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91030-4516
Practice Address - Country:US
Practice Address - Phone:310-478-3711
Practice Address - Fax:310-268-3279
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY32086225800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY32086Medicare ID - Type UnspecifiedCERTIFICATION CTRS