Provider Demographics
NPI:1659920650
Name:SMITH, MISTY RENE (PTA)
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:RENE
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 1:5934 COUNTY ROAD 289
Mailing Address - Street 2:
Mailing Address - City:SWEENY
Mailing Address - State:TX
Mailing Address - Zip Code:77480-4024
Mailing Address - Country:US
Mailing Address - Phone:979-533-9158
Mailing Address - Fax:
Practice Address - Street 1:5934 COUNTY ROAD 289
Practice Address - Street 2:
Practice Address - City:SWEENY
Practice Address - State:TX
Practice Address - Zip Code:77480-4024
Practice Address - Country:US
Practice Address - Phone:979-533-9158
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-11
Last Update Date:2019-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2071171225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant