Provider Demographics
NPI:1356372114
Name:SMITH, CONNIE LEE (OTR)
Entity type:Individual
Prefix:
First Name:CONNIE
Middle Name:LEE
Last Name:SMITH
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:CONNIE
Other - Middle Name:LEE
Other - Last Name:LOOMIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR
Mailing Address - Street 1:903 IRON ST
Mailing Address - Street 2:
Mailing Address - City:NORWAY
Mailing Address - State:MI
Mailing Address - Zip Code:49870-1003
Mailing Address - Country:US
Mailing Address - Phone:906-563-5139
Mailing Address - Fax:906-774-1570
Practice Address - Street 1:903 IRON ST
Practice Address - Street 2:
Practice Address - City:NORWAY
Practice Address - State:MI
Practice Address - Zip Code:49870-1003
Practice Address - Country:US
Practice Address - Phone:906-563-5139
Practice Address - Fax:906-774-1570
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2013-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201005739225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist