Provider Demographics
NPI:1851407670
Name:SMITH, TODD MICHAEL (RPT)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:MICHAEL
Last Name:SMITH
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:950 E COUNTY LINE RD
Mailing Address - Street 2:SUITE D
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-1928
Mailing Address - Country:US
Mailing Address - Phone:601-899-0002
Mailing Address - Fax:601-899-0088
Practice Address - Street 1:950 E COUNTY LINE RD
Practice Address - Street 2:SUITE D
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-1928
Practice Address - Country:US
Practice Address - Phone:601-899-0002
Practice Address - Fax:601-899-0088
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2015-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT3952225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06225721Medicaid