Provider Demographics
NPI:1942564265
Name:SMITH, MATTHEW JAMES (OTR)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:JAMES
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 1:304 BROADHEAD DR
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48642-8103
Mailing Address - Country:US
Mailing Address - Phone:989-295-1291
Mailing Address - Fax:
Practice Address - Street 1:3491 S HURON RD
Practice Address - Street 2:
Practice Address - City:BAY CITY
Practice Address - State:MI
Practice Address - Zip Code:48706-1547
Practice Address - Country:US
Practice Address - Phone:989-667-6469
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-02
Last Update Date:2012-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201003229225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist