Provider Demographics
NPI:1013176742
Name:SMITH, MARY JOSEPHINE (COTA)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:JOSEPHINE
Last Name:SMITH
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1711 STEVENS AVE
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46516-4002
Mailing Address - Country:US
Mailing Address - Phone:574-333-1120
Mailing Address - Fax:
Practice Address - Street 1:2400 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46528-5010
Practice Address - Country:US
Practice Address - Phone:574-533-0351
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-06
Last Update Date:2008-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32001082A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN32001082AOtherSTATE LICENSE