Provider Demographics
NPI:1104993880
Name:SMITH, ADELE M (RPT ATC)
Entity type:Individual
Prefix:
First Name:ADELE
Middle Name:M
Last Name:SMITH
Suffix:
Gender:F
Credentials:RPT ATC
Other - Prefix:
Other - First Name:ADELE
Other - Middle Name:M
Other - Last Name:SEVERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPT ATC
Mailing Address - Street 1:PO BOX 425789
Mailing Address - Street 2:E23
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02142-0015
Mailing Address - Country:US
Mailing Address - Phone:617-253-0556
Mailing Address - Fax:
Practice Address - Street 1:77 MASSACHUSETTS AVE
Practice Address - Street 2:E23-395
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02139-4301
Practice Address - Country:US
Practice Address - Phone:617-253-0556
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3058225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAY68212OtherBLUE CROSS BLUE SHIELD
MAY68212OtherBLUE CROSS BLUE SHIELD