Provider Demographics
NPI:1124517552
Name:SMITH, REBECCA A (PTA)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:A
Last Name:SMITH
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1251 CHANNINGWAY DR APT B
Mailing Address - Street 2:
Mailing Address - City:FAIRBORN
Mailing Address - State:OH
Mailing Address - Zip Code:45324-8713
Mailing Address - Country:US
Mailing Address - Phone:937-750-3618
Mailing Address - Fax:
Practice Address - Street 1:101 MILLS PL
Practice Address - Street 2:
Practice Address - City:NEW LEBANON
Practice Address - State:OH
Practice Address - Zip Code:45345-1430
Practice Address - Country:US
Practice Address - Phone:937-687-1311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-01
Last Update Date:2018-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPTA011498225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant