Provider Demographics
NPI:1700298825
Name:SMITH, DAVID (PTA)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1566 W 1825 S
Mailing Address - Street 2:
Mailing Address - City:WOODS CROSS
Mailing Address - State:UT
Mailing Address - Zip Code:84087-2283
Mailing Address - Country:US
Mailing Address - Phone:801-518-8540
Mailing Address - Fax:
Practice Address - Street 1:1566 W 1825 S
Practice Address - Street 2:
Practice Address - City:WOODS CROSS
Practice Address - State:UT
Practice Address - Zip Code:84087-2283
Practice Address - Country:US
Practice Address - Phone:801-518-8540
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-22
Last Update Date:2014-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7393554-2402225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant