Provider Demographics
NPI:1790494425
Name:SMITH, DIANE
Entity Type:Individual
Prefix:
First Name:DIANE
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 1:3325 THEODORE AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45405-2553
Mailing Address - Country:US
Mailing Address - Phone:937-231-4928
Mailing Address - Fax:
Practice Address - Street 1:5305 N MAIN ST
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45415-3644
Practice Address - Country:US
Practice Address - Phone:937-231-4928
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-21
Last Update Date:2022-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH33.023464225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist