Provider Demographics
NPI:1750576559
Name:SMITH, ELISSA (OTR/L)
Entity type:Individual
Prefix:
First Name:ELISSA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
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:PO BOX 776
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:KY
Mailing Address - Zip Code:42539-0776
Mailing Address - Country:US
Mailing Address - Phone:606-787-6337
Mailing Address - Fax:
Practice Address - Street 1:745 CAMPBELLSVILLE ST
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:KY
Practice Address - Zip Code:42539-3107
Practice Address - Country:US
Practice Address - Phone:606-706-0304
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-14
Last Update Date:2007-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY-R3448171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor