Provider Demographics
NPI:1689628554
Name:SMITH, PHILLIP KEN (OT)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:KEN
Last Name:SMITH
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 ASSOCIATES DR
Mailing Address - Street 2:
Mailing Address - City:DUBUQUE
Mailing Address - State:IA
Mailing Address - Zip Code:52002-2201
Mailing Address - Country:US
Mailing Address - Phone:563-584-4100
Mailing Address - Fax:563-584-4110
Practice Address - Street 1:1500 ASSOCIATES DR
Practice Address - Street 2:
Practice Address - City:DUBUQUE
Practice Address - State:IA
Practice Address - Zip Code:52002-2201
Practice Address - Country:US
Practice Address - Phone:563-584-4465
Practice Address - Fax:563-584-4395
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00252225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand