Provider Demographics
NPI:1811049364
Name:SMITH, ANGELA LEA (PT, MSPT, OCS)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:LEA
Last Name:SMITH
Suffix:
Gender:F
Credentials:PT, MSPT, OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6887 S 3300 W
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84084-1700
Mailing Address - Country:US
Mailing Address - Phone:801-918-7909
Mailing Address - Fax:
Practice Address - Street 1:6887 S 3300 W
Practice Address - Street 2:
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84084-1700
Practice Address - Country:US
Practice Address - Phone:801-918-7909
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2012-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4962365-2401225100000X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic