Provider Demographics
NPI:1811596869
Name:SMITH, TYLER (DPT)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 MAIN ST FL 2
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:CA
Mailing Address - Zip Code:90291-3626
Mailing Address - Country:US
Mailing Address - Phone:888-859-0145
Mailing Address - Fax:888-858-1601
Practice Address - Street 1:1600 MAIN ST FL 2
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:CA
Practice Address - Zip Code:90291-3626
Practice Address - Country:US
Practice Address - Phone:888-859-0145
Practice Address - Fax:888-858-1601
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-21
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT298820225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist