Provider Demographics
NPI:1194904359
Name:SMITH, LAURA V (OTR/L MOT)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:V
Last Name:SMITH
Suffix:
Gender:F
Credentials:OTR/L MOT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12615 BRADY PLACE BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32223-2590
Mailing Address - Country:US
Mailing Address - Phone:904-755-1311
Mailing Address - Fax:
Practice Address - Street 1:12615 BRADY PLACE BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32223-2590
Practice Address - Country:US
Practice Address - Phone:904-755-1311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-24
Last Update Date:2011-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL12624225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000306200Medicaid