Provider Demographics
NPI:1184874315
Name:SMITH, MICHELE LEE (PTA)
Entity type:Individual
Prefix:MS
First Name:MICHELE
Middle Name:LEE
Last Name:SMITH
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MRS
Other - First Name:MICHELE
Other - Middle Name:LEE
Other - Last Name:ROGERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4539 SODA PKWY
Mailing Address - Street 2:
Mailing Address - City:HAMBURG
Mailing Address - State:NY
Mailing Address - Zip Code:14075-1015
Mailing Address - Country:US
Mailing Address - Phone:716-445-3958
Mailing Address - Fax:
Practice Address - Street 1:106 PINE ST.
Practice Address - Street 2:
Practice Address - City:HAMBURG
Practice Address - State:NY
Practice Address - Zip Code:14075
Practice Address - Country:US
Practice Address - Phone:716-646-0048
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-24
Last Update Date:2016-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005003-1225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant