Provider Demographics
NPI:1750087524
Name:SMITH, JUSTIN (DPT)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:537 PARKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:ROSE HILL
Mailing Address - State:KS
Mailing Address - Zip Code:67133-9580
Mailing Address - Country:US
Mailing Address - Phone:719-220-4686
Mailing Address - Fax:
Practice Address - Street 1:731 N KLEIN CIR
Practice Address - Street 2:
Practice Address - City:DERBY
Practice Address - State:KS
Practice Address - Zip Code:67037-7011
Practice Address - Country:US
Practice Address - Phone:316-719-2400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-03
Last Update Date:2023-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11-063312251G0304X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS11-06331OtherKANSAS PHYSICAL THERAPY LICENSE