Provider Demographics
NPI:1104460294
Name:SMITH, AUSTIN CHASE
Entity type:Individual
Prefix:
First Name:AUSTIN
Middle Name:CHASE
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13915 MOPAC SERVICE RD
Mailing Address - Street 2:#200
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78728
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13915 MOPAC SERVICE RD
Practice Address - Street 2:#200
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78728
Practice Address - Country:US
Practice Address - Phone:941-223-0045
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-31
Last Update Date:2019-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPTA-2150133225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant