Provider Demographics
NPI:1447361431
Name:SMITH, DEBORAH SUE (PT)
Entity type:Individual
Prefix:
First Name:DEBORAH
Middle Name:SUE
Last Name:SMITH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:861 HEALTH PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-7383
Mailing Address - Country:US
Mailing Address - Phone:810-953-0095
Mailing Address - Fax:810-953-0031
Practice Address - Street 1:861 HEALTH PARK BLVD
Practice Address - Street 2:
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439-7383
Practice Address - Country:US
Practice Address - Phone:810-953-0095
Practice Address - Fax:810-953-0031
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2008-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501003633225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI30610OtherBCBSM
MI236556Medicare PIN