Provider Demographics
NPI:1235341553
Name:SMITH, SHARRON BUSH (LOTR)
Entity type:Individual
Prefix:MRS
First Name:SHARRON
Middle Name:BUSH
Last Name:SMITH
Suffix:
Gender:F
Credentials:LOTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 RAPHAEL DR
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-5952
Mailing Address - Country:US
Mailing Address - Phone:337-849-7431
Mailing Address - Fax:
Practice Address - Street 1:102 RAPHAEL DR
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-5952
Practice Address - Country:US
Practice Address - Phone:337-849-7431
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2019-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAOTT.Z10814225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1306843Medicaid