Provider Demographics
NPI:1821759150
Name:SMITH, CHANDRA FAYE (OTR/L)
Entity Type:Individual
Prefix:MISS
First Name:CHANDRA
Middle Name:FAYE
Last Name:SMITH
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4545 E 1000TH AVE
Mailing Address - Street 2:
Mailing Address - City:ALTAMONT
Mailing Address - State:IL
Mailing Address - Zip Code:62411-3414
Mailing Address - Country:US
Mailing Address - Phone:618-322-8588
Mailing Address - Fax:
Practice Address - Street 1:503 N MAPLE ST
Practice Address - Street 2:
Practice Address - City:EFFINGHAM
Practice Address - State:IL
Practice Address - Zip Code:62401-2099
Practice Address - Country:US
Practice Address - Phone:217-342-2121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-08
Last Update Date:2022-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056014048225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist