Provider Demographics
NPI:1891769790
Name:SMITH, GAIL DEANN (PT)
Entity Type:Individual
Prefix:
First Name:GAIL
Middle Name:DEANN
Last Name:SMITH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:GAIL
Other - Middle Name:DEANN
Other - Last Name:ROURKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:56749 SPRING RIVER LOOP
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97707
Mailing Address - Country:US
Mailing Address - Phone:541-593-6167
Mailing Address - Fax:541-593-0316
Practice Address - Street 1:56881 ENTERPRISE DR
Practice Address - Street 2:
Practice Address - City:SUNRIVER
Practice Address - State:OR
Practice Address - Zip Code:97707
Practice Address - Country:US
Practice Address - Phone:541-593-8535
Practice Address - Fax:541-593-0316
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-15
Last Update Date:2010-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1375225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR184473Medicaid
00WCXBRMedicare ID - Type Unspecified
OR184473Medicaid