Provider Demographics
NPI:1104195593
Name:SMITH, RACHEAL MARIE (ATC, LAT)
Entity type:Individual
Prefix:MISS
First Name:RACHEAL
Middle Name:MARIE
Last Name:SMITH
Suffix:
Gender:F
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 W 93RD PL
Mailing Address - Street 2:APT 116
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46307-2291
Mailing Address - Country:US
Mailing Address - Phone:815-238-8415
Mailing Address - Fax:
Practice Address - Street 1:1950 45TH AVE
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-3927
Practice Address - Country:US
Practice Address - Phone:219-924-7316
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-14
Last Update Date:2011-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36001883A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer