Provider Demographics
NPI:1154743649
Name:SMITH, SANDRA MAE (PHYSICAL THERAPIST A)
Entity type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:MAE
Last Name:SMITH
Suffix:
Gender:F
Credentials:PHYSICAL THERAPIST A
Other - Prefix:MRS
Other - First Name:SANDRA
Other - Middle Name:MAE
Other - Last Name:FRUITS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHYSICAL THERAPIST A
Mailing Address - Street 1:430 LILY RD. NE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506
Mailing Address - Country:US
Mailing Address - Phone:360-491-9700
Mailing Address - Fax:
Practice Address - Street 1:430 LILY RD. NE
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506
Practice Address - Country:US
Practice Address - Phone:360-491-9700
Practice Address - Fax:360-923-5330
Is Sole Proprietor?:No
Enumeration Date:2014-01-17
Last Update Date:2014-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAP160043450225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant