Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | PT010720 | GA |
NPI | 1003150764 |
---|---|
Provider Name | Dr. Mary Elizabeth Smith |
First Address | North Augusta, SC 29841-3817 |
Second Address | North Augusta, SC 29841-3817 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 19/11/2012 |
Last Update Date | 19/11/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
PT010720 | PHYSICAL THERAPY LICENSE NUMBER (01) | GA |