Provider Demographics
NPI:1265607295
Name:SMITH, MARIA SOCORRO MIEL (PT)
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:SOCORRO MIEL
Last Name:SMITH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MA
Other - Middle Name:SOCORRO MIEL
Other - Last Name:CASTUERA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:2699 N 17TH ST
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-2134
Mailing Address - Country:US
Mailing Address - Phone:541-266-3604
Mailing Address - Fax:
Practice Address - Street 1:2645 N 17TH ST
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-2134
Practice Address - Country:US
Practice Address - Phone:541-267-5395
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-30
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501012505225100000X
OR62584225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist