Provider Demographics
NPI:1720199631
Name:SMITH, DIANA (MPT)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1450 NORTHWEST BLVD STE 106
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-5605
Mailing Address - Country:US
Mailing Address - Phone:208-772-6609
Mailing Address - Fax:208-664-4313
Practice Address - Street 1:1875 N LAKEWOOD DR STE 101
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-4928
Practice Address - Country:US
Practice Address - Phone:208-667-6264
Practice Address - Fax:208-664-4313
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2020-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT1584225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807043800Medicaid
ID1655803Medicare ID - Type UnspecifiedIRONWOOD CLINIC
ID807043800Medicaid