Provider Demographics
NPI:1851073019
Name:SMITH, TAVIA KYNDRA (DPT)
Entity Type:Individual
Prefix:
First Name:TAVIA
Middle Name:KYNDRA
Last Name:SMITH
Suffix:
Gender:F
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:PO BOX 2650
Mailing Address - Street 2:
Mailing Address - City:COPPELL
Mailing Address - State:TX
Mailing Address - Zip Code:75019-8607
Mailing Address - Country:US
Mailing Address - Phone:972-724-2400
Mailing Address - Fax:972-724-2495
Practice Address - Street 1:2445 W OAK ST STE 200
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76201-4326
Practice Address - Country:US
Practice Address - Phone:940-320-6030
Practice Address - Fax:940-320-3113
Is Sole Proprietor?:No
Enumeration Date:2023-08-07
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1381026225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist