Provider Demographics
NPI:1851730600
Name:SMULLEN, EARL RANDALL (PTA)
Entity Type:Individual
Prefix:MR
First Name:EARL
Middle Name:RANDALL
Last Name:SMULLEN
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 GORDY ST
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:DE
Mailing Address - Zip Code:19947-2116
Mailing Address - Country:US
Mailing Address - Phone:302-854-6677
Mailing Address - Fax:
Practice Address - Street 1:12 GORDY ST
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:DE
Practice Address - Zip Code:19947-2116
Practice Address - Country:US
Practice Address - Phone:302-854-6677
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-14
Last Update Date:2013-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEJJ20000757225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant