Provider Demographics
NPI:1891118071
Name:DISMUKE, ERNEST JR (OT R/L)
Entity Type:Individual
Prefix:MR
First Name:ERNEST
Middle Name:
Last Name:DISMUKE
Suffix:JR
Gender:M
Credentials:OT R/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 WOODHAVEN DR
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:TN
Mailing Address - Zip Code:37167-4179
Mailing Address - Country:US
Mailing Address - Phone:615-594-1075
Mailing Address - Fax:615-220-2358
Practice Address - Street 1:601 WOODHAVEN DR
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:TN
Practice Address - Zip Code:37167-4179
Practice Address - Country:US
Practice Address - Phone:615-594-1075
Practice Address - Fax:615-220-2358
Is Sole Proprietor?:No
Enumeration Date:2014-01-24
Last Update Date:2014-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3072225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist