Provider Demographics
NPI:1285955104
Name:SMITH, SCOTT STUART (PT)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:STUART
Last Name:SMITH
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:507 W DOUGHTY ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:MN
Mailing Address - Zip Code:55041-1500
Mailing Address - Country:US
Mailing Address - Phone:651-345-2350
Mailing Address - Fax:651-345-2238
Practice Address - Street 1:507 W DOUGHTY ST
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:MN
Practice Address - Zip Code:55041-1500
Practice Address - Country:US
Practice Address - Phone:651-345-2350
Practice Address - Fax:651-345-2238
Is Sole Proprietor?:No
Enumeration Date:2010-06-15
Last Update Date:2020-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305210973225100000X
MN9547225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI61049OtherDEAN HEALTH INSURANCE