Provider Demographics
NPI:1205246964
Name:SMITH, ALFRED EDWARD JR (CMT)
Entity type:Individual
Prefix:
First Name:ALFRED
Middle Name:EDWARD
Last Name:SMITH
Suffix:JR
Gender:M
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1645 LASKIN RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23451-6199
Mailing Address - Country:US
Mailing Address - Phone:757-240-6049
Mailing Address - Fax:
Practice Address - Street 1:1645 LASKIN RD
Practice Address - Street 2:SUITE 104
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23451-6199
Practice Address - Country:US
Practice Address - Phone:757-240-6049
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-04
Last Update Date:2016-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0019012425225700000X, 225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist