Provider Demographics
NPI:1265930770
Name:SMITH, JANINE LOUISE (PTA)
Entity type:Individual
Prefix:
First Name:JANINE
Middle Name:LOUISE
Last Name:SMITH
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1397 S LINDEN RD STE B
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532-4194
Mailing Address - Country:US
Mailing Address - Phone:810-230-9750
Mailing Address - Fax:
Practice Address - Street 1:1397 S LINDEN RD STE B
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48532-4194
Practice Address - Country:US
Practice Address - Phone:810-230-9750
Practice Address - Fax:810-230-9750
Is Sole Proprietor?:No
Enumeration Date:2018-01-30
Last Update Date:2018-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502000495225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI383499025Medicaid