Provider Demographics
NPI:1871948661
Name:SMELTZER-WIDEMAN, LORI M (LMT)
Entity type:Individual
Prefix:MRS
First Name:LORI
Middle Name:M
Last Name:SMELTZER-WIDEMAN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:414 EASTBURN CT
Mailing Address - Street 2:
Mailing Address - City:DARLINGTON
Mailing Address - State:SC
Mailing Address - Zip Code:29532-2716
Mailing Address - Country:US
Mailing Address - Phone:843-319-6855
Mailing Address - Fax:
Practice Address - Street 1:1212 HARRY BYRD HWY
Practice Address - Street 2:
Practice Address - City:DARLINGTON
Practice Address - State:SC
Practice Address - Zip Code:29532-3509
Practice Address - Country:US
Practice Address - Phone:843-393-1107
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-28
Last Update Date:2016-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC10207225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist