1780840538 NPI number — KATIE J SMITH D.P.T.

Table of content: KATIE J SMITH D.P.T. (NPI 1780840538)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780840538 NPI number — KATIE J SMITH D.P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMITH
Provider First Name:
KATIE
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.P.T.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1780840538
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/27/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4000 N PROVIDENCE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
APPLETON
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54913-8018
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
920-257-2000
Provider Business Mailing Address Fax Number:
920-257-2004

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
220 3RD AVE W
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
ASHLAND
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54806-1616
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-685-9656
Provider Business Practice Location Address Fax Number:
715-685-9544
Provider Enumeration Date:
07/31/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  11067-024 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 36186100 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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