Provider Demographics
NPI:1619318706
Name:SMITH, CAROLYN (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:MS
First Name:CAROLYN
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1108 W LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63640-1922
Mailing Address - Country:US
Mailing Address - Phone:913-406-3865
Mailing Address - Fax:
Practice Address - Street 1:1108 W LIBERTY ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MO
Practice Address - Zip Code:63640-1922
Practice Address - Country:US
Practice Address - Phone:816-438-0004
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-17
Last Update Date:2014-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO108235225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist