Provider Demographics
NPI:1942531850
Name:SMIDDY, CRYSTAL G
Entity Type:Individual
Prefix:MRS
First Name:CRYSTAL
Middle Name:G
Last Name:SMIDDY
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 1:286 HATFIELD ST
Mailing Address - Street 2:
Mailing Address - City:JELLICO
Mailing Address - State:TN
Mailing Address - Zip Code:37762-2616
Mailing Address - Country:US
Mailing Address - Phone:606-280-5955
Mailing Address - Fax:
Practice Address - Street 1:286 HATFIELD ST
Practice Address - Street 2:
Practice Address - City:JELLICO
Practice Address - State:TN
Practice Address - Zip Code:37762-2616
Practice Address - Country:US
Practice Address - Phone:606-280-5955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-18
Last Update Date:2019-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist