Provider Demographics
NPI:1447868658
Name:SMYLIE, MEREDITH RAE (MPT)
Entity type:Individual
Prefix:
First Name:MEREDITH
Middle Name:RAE
Last Name:SMYLIE
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:MEREDITH
Other - Middle Name:RAE
Other - Last Name:SMYLIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPT
Mailing Address - Street 1:4236 YOUNGER WAY
Mailing Address - Street 2:
Mailing Address - City:CARMICHAEL
Mailing Address - State:CA
Mailing Address - Zip Code:95608-6648
Mailing Address - Country:US
Mailing Address - Phone:916-505-2067
Mailing Address - Fax:
Practice Address - Street 1:8685 GREENBACK LN
Practice Address - Street 2:
Practice Address - City:ORANGEVALE
Practice Address - State:CA
Practice Address - Zip Code:95662-3987
Practice Address - Country:US
Practice Address - Phone:916-505-2067
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-14
Last Update Date:2020-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22431225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist