Provider Demographics
NPI:1952496234
Name:SMITH, BETH MIRASOLA (PT)
Entity Type:Individual
Prefix:
First Name:BETH
Middle Name:MIRASOLA
Last Name:SMITH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1202 COUNTY ROAD PH STE 100
Mailing Address - Street 2:
Mailing Address - City:ONALASKA
Mailing Address - State:WI
Mailing Address - Zip Code:54650-8440
Mailing Address - Country:US
Mailing Address - Phone:608-781-6828
Mailing Address - Fax:
Practice Address - Street 1:1202 COUNTY ROAD PH STE 100
Practice Address - Street 2:
Practice Address - City:ONALASKA
Practice Address - State:WI
Practice Address - Zip Code:54650-8440
Practice Address - Country:US
Practice Address - Phone:608-781-6828
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2014-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3152225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist