Provider Demographics
NPI:1942572854
Name:SMITH, ROSE MARIE (PTA)
Entity Type:Individual
Prefix:
First Name:ROSE
Middle Name:MARIE
Last Name:SMITH
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:257 SW DADE ST
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:FL
Mailing Address - Zip Code:32340-2361
Mailing Address - Country:US
Mailing Address - Phone:850-973-3316
Mailing Address - Fax:850-973-1261
Practice Address - Street 1:257 SW DADE ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:FL
Practice Address - Zip Code:32340-2361
Practice Address - Country:US
Practice Address - Phone:850-973-3316
Practice Address - Fax:850-973-1261
Is Sole Proprietor?:No
Enumeration Date:2012-02-08
Last Update Date:2012-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA22947225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant