Provider Demographics
NPI:1609450972
Name:SMITH, MAX HENRY (PTA)
Entity Type:Individual
Prefix:
First Name:MAX
Middle Name:HENRY
Last Name:SMITH
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:906 THOMPSON ST UNIT 3210
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:VA
Mailing Address - Zip Code:23005-1128
Mailing Address - Country:US
Mailing Address - Phone:804-798-3291
Mailing Address - Fax:
Practice Address - Street 1:906 THOMPSON ST UNIT 3210
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:VA
Practice Address - Zip Code:23005-1128
Practice Address - Country:US
Practice Address - Phone:804-798-3291
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-12
Last Update Date:2021-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306605658225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant