Provider Demographics
NPI:1952423584
Name:SMITH, MISTY LYNN (ITFS)
Entity type:Individual
Prefix:MISS
First Name:MISTY
Middle Name:LYNN
Last Name:SMITH
Suffix:
Gender:F
Credentials:ITFS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 TRENT ST
Mailing Address - Street 2:
Mailing Address - City:ROCKINGHAM
Mailing Address - State:NC
Mailing Address - Zip Code:28379-8979
Mailing Address - Country:US
Mailing Address - Phone:910-995-2860
Mailing Address - Fax:
Practice Address - Street 1:10 PARKER LN
Practice Address - Street 2:
Practice Address - City:PINEHURST
Practice Address - State:NC
Practice Address - Zip Code:28374-7903
Practice Address - Country:US
Practice Address - Phone:910-295-3133
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3403400Medicaid