Provider Demographics
NPI:1871678987
Name:SMITH, HEATHER ANN (PT)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:ANN
Last Name:SMITH
Suffix:
Gender:F
Credentials:PT
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 73
Mailing Address - Street 2:
Mailing Address - City:OCEAN GROVE
Mailing Address - State:NJ
Mailing Address - Zip Code:07756-0073
Mailing Address - Country:US
Mailing Address - Phone:908-309-8798
Mailing Address - Fax:732-774-6744
Practice Address - Street 1:218 2ND AVE
Practice Address - Street 2:203E
Practice Address - City:ASBURY PARK
Practice Address - State:NJ
Practice Address - Zip Code:07712-6255
Practice Address - Country:US
Practice Address - Phone:908-309-8798
Practice Address - Fax:732-774-6744
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00868900208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ051497SY2Medicare ID - Type Unspecified