Provider Demographics
NPI:1225852528
Name:SMITH, MICAH BROOKE WOODS (PT)
Entity type:Individual
Prefix:
First Name:MICAH BROOKE
Middle Name:WOODS
Last Name:SMITH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:921 W BEACON ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:MS
Mailing Address - Zip Code:39350-3229
Mailing Address - Country:US
Mailing Address - Phone:601-650-0002
Mailing Address - Fax:601-898-3699
Practice Address - Street 1:201 SOUTH BROOKS AVE
Practice Address - Street 2:
Practice Address - City:PELAHATCHIE
Practice Address - State:MS
Practice Address - Zip Code:39145-0001
Practice Address - Country:US
Practice Address - Phone:601-759-5006
Practice Address - Fax:601-759-5014
Is Sole Proprietor?:No
Enumeration Date:2024-11-13
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT7551225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist