Provider Demographics
NPI:1255170080
Name:SMITH, KAITLYN L (DPT, PT)
Entity type:Individual
Prefix:
First Name:KAITLYN
Middle Name:L
Last Name:SMITH
Suffix:
Gender:F
Credentials:DPT, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:773 ST REGIS AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGDALE
Mailing Address - State:NY
Mailing Address - Zip Code:12913-2114
Mailing Address - Country:US
Mailing Address - Phone:518-637-8212
Mailing Address - Fax:
Practice Address - Street 1:7165 COLUMBIA GATEWAY DR STE A
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21046-2145
Practice Address - Country:US
Practice Address - Phone:443-441-0616
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-21
Last Update Date:2024-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDAPPLIED208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation