Provider Demographics
NPI:1659670677
Name:SMITH, EDWARD L (DPT, ATC)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:L
Last Name:SMITH
Suffix:
Gender:M
Credentials:DPT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 SAINT MARY ST
Mailing Address - Street 2:
Mailing Address - City:THIBODAUX
Mailing Address - State:LA
Mailing Address - Zip Code:70301-2627
Mailing Address - Country:US
Mailing Address - Phone:985-446-9565
Mailing Address - Fax:985-446-9577
Practice Address - Street 1:525 SAINT MARY ST
Practice Address - Street 2:
Practice Address - City:THIBODAUX
Practice Address - State:LA
Practice Address - Zip Code:70301-2627
Practice Address - Country:US
Practice Address - Phone:985-446-9565
Practice Address - Fax:985-446-9577
Is Sole Proprietor?:No
Enumeration Date:2011-03-16
Last Update Date:2011-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA07590225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist