Provider Demographics
NPI:1740212380
Name:SMITH, CASONDRA
Entity Type:Individual
Prefix:
First Name:CASONDRA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:945 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BOONEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72927-3843
Mailing Address - Country:US
Mailing Address - Phone:479-632-6337
Mailing Address - Fax:479-632-5916
Practice Address - Street 1:3918 PECAN GROVE RD
Practice Address - Street 2:
Practice Address - City:RUDY
Practice Address - State:AR
Practice Address - Zip Code:72952-9026
Practice Address - Country:US
Practice Address - Phone:479-632-6337
Practice Address - Fax:479-632-5916
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROTR2010225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5Y749OtherBLUE CROSS BS PROV #