Provider Demographics
NPI:1255379087
Name:SMITH, KATHERINE ANNE M (MPT)
Entity type:Individual
Prefix:
First Name:KATHERINE ANNE
Middle Name:M
Last Name:SMITH
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:A
Other - Last Name:MONTLEAON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2222
Mailing Address - Fax:
Practice Address - Street 1:93 SPRINGVIEW LN UNIT B
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29485-8143
Practice Address - Country:US
Practice Address - Phone:843-900-6381
Practice Address - Fax:843-875-4396
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2017-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT28408225100000X
SC6404225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist