Provider Demographics
NPI:1134863426
Name:SMITH, GWENDOLYN (LAT, ATC)
Entity type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:
Last Name:SMITH
Suffix:
Gender:
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 MOHAWK ST FL 1
Mailing Address - Street 2:
Mailing Address - City:COHOES
Mailing Address - State:NY
Mailing Address - Zip Code:12047-3017
Mailing Address - Country:US
Mailing Address - Phone:413-847-0178
Mailing Address - Fax:
Practice Address - Street 1:1400 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12222-3707
Practice Address - Country:US
Practice Address - Phone:518-442-3725
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-23
Last Update Date:2025-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAATL37632255A2300X
MA390200000X
CT17472255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program