Provider Demographics
NPI:1942061528
Name:SMITH, ETHAN (OTR)
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2350 S WADE DR UNIT 2090
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85295-0453
Mailing Address - Country:US
Mailing Address - Phone:801-372-7114
Mailing Address - Fax:
Practice Address - Street 1:2350 S WADE DR UNIT 2090
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85295-0453
Practice Address - Country:US
Practice Address - Phone:801-372-7114
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-19
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist