Provider Demographics
NPI:1740029446
Name:SMITH, CARLTON JR (OTR/L)
Entity type:Individual
Prefix:
First Name:CARLTON
Middle Name:
Last Name:SMITH
Suffix:JR
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:922 HARBOR AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46615-3426
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:922 HARBOR AVE
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46615-3426
Practice Address - Country:US
Practice Address - Phone:574-315-6093
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-22
Last Update Date:2024-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31007737A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist