Provider Demographics
NPI:1790762680
Name:SMITH, LISA NICOLE (PT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:NICOLE
Last Name:SMITH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7575 5 MILE RD
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45230-4346
Mailing Address - Country:US
Mailing Address - Phone:513-233-4360
Mailing Address - Fax:513-233-4361
Practice Address - Street 1:7575 5 MILE RD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45230-4346
Practice Address - Country:US
Practice Address - Phone:513-233-4360
Practice Address - Fax:513-233-4361
Is Sole Proprietor?:No
Enumeration Date:2005-12-30
Last Update Date:2014-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT007177225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHP00334373OtherMEDICARE RAILROAD
OH2632520Medicaid
OH9139525OtherPHCS
OH000000383362OtherANTHEM
OHH244310Medicare PIN
OH000000383362OtherANTHEM
OH9139525OtherPHCS