Provider Demographics
NPI:1609925056
Name:SMITH, STANLEY (PT)
Entity Type:Individual
Prefix:
First Name:STANLEY
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:323 S 18TH AVE
Mailing Address - Street 2:
Mailing Address - City:STURGEON BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54235-1401
Mailing Address - Country:US
Mailing Address - Phone:920-854-4111
Mailing Address - Fax:
Practice Address - Street 1:2311 MEADOW WOOD DR
Practice Address - Street 2:
Practice Address - City:SISTER BAY
Practice Address - State:WI
Practice Address - Zip Code:54234-9006
Practice Address - Country:US
Practice Address - Phone:920-854-4111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2021-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13902-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL070-003669OtherPT STATE LICENSE #
IL070-003669OtherPT STATE LICENSE #