Provider Demographics
NPI:1750465100
Name:SMITH, KATHLEEN MARY (PT)
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:MARY
Last Name:SMITH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1111 RONALD REAGAN PKWY
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:IN
Mailing Address - Zip Code:46123-7085
Mailing Address - Country:US
Mailing Address - Phone:317-217-3070
Mailing Address - Fax:317-217-3073
Practice Address - Street 1:133 W MAIN ST
Practice Address - Street 2:SUITE 120
Practice Address - City:NORTHVILLE
Practice Address - State:MI
Practice Address - Zip Code:48167-1520
Practice Address - Country:US
Practice Address - Phone:248-347-1188
Practice Address - Fax:248-347-1252
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2008-11-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5501002674225100000X
IN05009688A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist