Basic Information
| Provider Information | |||||||||
| NPI: | 1013176742 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | JOSEPHINE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | COTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1711 STEVENS AVE | ||||||||
| Address2: | |||||||||
| City: | ELKHART | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465164002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5743331120 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2400 COLLEGE AVE | ||||||||
| Address2: | |||||||||
| City: | GOSHEN | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465285010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5745330351 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2008 | ||||||||
| LastUpdateDate: | 06/06/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | 32001082A | IN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
ID Information
| ID | Type | State | Issuer | Description | 32001082A | 01 | IN | STATE LICENSE | OTHER |