Provider Demographics
NPI:1972631562
Name:SMITH, IRIS SUSAN
Entity Type:Individual
Prefix:
First Name:IRIS
Middle Name:SUSAN
Last Name:SMITH
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 1:11130 LOST CREEK TER
Mailing Address - Street 2:APT 203
Mailing Address - City:LAKEWOOD RANCH
Mailing Address - State:FL
Mailing Address - Zip Code:34211-9353
Mailing Address - Country:US
Mailing Address - Phone:941-465-5904
Mailing Address - Fax:727-767-4715
Practice Address - Street 1:501 6TH AVE S
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-4634
Practice Address - Country:US
Practice Address - Phone:727-767-6761
Practice Address - Fax:727-767-4715
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2015-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist