Provider Demographics
NPI:1639462559
Name:SMITH, FELICIA DAWN
Entity Type:Individual
Prefix:
First Name:FELICIA
Middle Name:DAWN
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 DAWES CIR
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:OH
Mailing Address - Zip Code:45750-1516
Mailing Address - Country:US
Mailing Address - Phone:740-525-4090
Mailing Address - Fax:
Practice Address - Street 1:128 DAWES CIR
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:OH
Practice Address - Zip Code:45750-1516
Practice Address - Country:US
Practice Address - Phone:740-525-4090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-25
Last Update Date:2012-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306602966225200000X
OHPTA.07679225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant