Provider Demographics
NPI:1962013599
Name:SMITH, SARAH (DPT)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:485 W 7750 N
Mailing Address - Street 2:
Mailing Address - City:TETONIA
Mailing Address - State:ID
Mailing Address - Zip Code:83452-1213
Mailing Address - Country:US
Mailing Address - Phone:208-390-3507
Mailing Address - Fax:
Practice Address - Street 1:73 N MAIN STREET
Practice Address - Street 2:
Practice Address - City:VICTOR
Practice Address - State:ID
Practice Address - Zip Code:83455
Practice Address - Country:US
Practice Address - Phone:208-787-6900
Practice Address - Fax:208-787-0946
Is Sole Proprietor?:No
Enumeration Date:2020-08-17
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-6984225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist