Provider Demographics
NPI:1871790907
Name:SMITH, CHRISTINA ANN (PTA)
Entity type:Individual
Prefix:MRS
First Name:CHRISTINA
Middle Name:ANN
Last Name:SMITH
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5131 WILLOW BROOK DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46835-1578
Mailing Address - Country:US
Mailing Address - Phone:260-450-8581
Mailing Address - Fax:260-492-1674
Practice Address - Street 1:5131 WILLOW BROOK DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46835-1578
Practice Address - Country:US
Practice Address - Phone:260-450-8581
Practice Address - Fax:260-492-1674
Is Sole Proprietor?:No
Enumeration Date:2007-07-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06002763A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1555-656Medicaid