Provider Demographics
NPI:1013517861
Name:SMITH, KEAGAN NICOLE (OTR/L)
Entity Type:Individual
Prefix:
First Name:KEAGAN
Middle Name:NICOLE
Last Name:SMITH
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8964 RAND AVE APT 4208
Mailing Address - Street 2:
Mailing Address - City:DAPHNE
Mailing Address - State:AL
Mailing Address - Zip Code:36526-9157
Mailing Address - Country:US
Mailing Address - Phone:251-455-4871
Mailing Address - Fax:
Practice Address - Street 1:424 SARALAND BLVD N STE F
Practice Address - Street 2:
Practice Address - City:SARALAND
Practice Address - State:AL
Practice Address - Zip Code:36571-2153
Practice Address - Country:US
Practice Address - Phone:251-455-4871
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-30
Last Update Date:2020-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL21211225X00000X
AL5371225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist