Provider Demographics
NPI:1679652499
Name:SMITH, MARY (OTR/L, CHT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:OTR/L, CHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 518
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30237
Mailing Address - Country:US
Mailing Address - Phone:770-631-8277
Mailing Address - Fax:770-631-9403
Practice Address - Street 1:2155 POST OAK TRITT RD
Practice Address - Street 2:SUITE 400
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062-8620
Practice Address - Country:US
Practice Address - Phone:770-565-4044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA001439225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGA001439OtherSTATE LISC NUMBER