Provider Demographics
NPI:1629469671
Name:SMITH, MOLLY (PTA)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3539 HARVEST LN
Mailing Address - Street 2:
Mailing Address - City:BARTLETT
Mailing Address - State:TN
Mailing Address - Zip Code:38133-2643
Mailing Address - Country:US
Mailing Address - Phone:901-409-6980
Mailing Address - Fax:
Practice Address - Street 1:3965 S MENDENHALL RD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38115-5914
Practice Address - Country:US
Practice Address - Phone:901-620-3900
Practice Address - Fax:901-620-3901
Is Sole Proprietor?:No
Enumeration Date:2015-02-12
Last Update Date:2015-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3290225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant