Provider Demographics
NPI:1669742821
Name:SMITH, ANDREA R (CMT)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:R
Last Name:SMITH
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:MISS
Other - First Name:ANDREA
Other - Middle Name:R
Other - Last Name:BRYAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:899 STATE ST
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:MI
Mailing Address - Zip Code:48813-1750
Mailing Address - Country:US
Mailing Address - Phone:517-599-5283
Mailing Address - Fax:
Practice Address - Street 1:106 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:MI
Practice Address - Zip Code:48813-1545
Practice Address - Country:US
Practice Address - Phone:517-599-5283
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-05
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI0225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist