Provider Demographics
NPI:1447579818
Name:SMYTH, SUSAN JANE (OTR/L)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:JANE
Last Name:SMYTH
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2117 W 25TH ST APT 1
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90732-4175
Mailing Address - Country:US
Mailing Address - Phone:310-521-8600
Mailing Address - Fax:310-521-9400
Practice Address - Street 1:2117 W 25TH ST APT 1
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90732-4175
Practice Address - Country:US
Practice Address - Phone:310-521-8600
Practice Address - Fax:310-521-9400
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-25
Last Update Date:2010-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT 6664174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHO742OtherREGIONAL CENTER