Provider Demographics
NPI:1891975025
Name:SMITH, HEATHER
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:
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 421718
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:SC
Mailing Address - Zip Code:29442-4203
Mailing Address - Country:US
Mailing Address - Phone:843-293-7085
Mailing Address - Fax:
Practice Address - Street 1:3515 CADUCEUS DR
Practice Address - Street 2:SUITE A
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29588-2922
Practice Address - Country:US
Practice Address - Phone:843-293-7085
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-05
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3005225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC3005OtherLICENSE