Provider Demographics
NPI:1306330071
Name:SMITH-WYNN, LATRESE (PT, DPT)
Entity type:Individual
Prefix:DR
First Name:LATRESE
Middle Name:
Last Name:SMITH-WYNN
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3141 E BENDING CREEK TRL
Mailing Address - Street 2:
Mailing Address - City:CRETE
Mailing Address - State:IL
Mailing Address - Zip Code:60417-3861
Mailing Address - Country:US
Mailing Address - Phone:773-330-0720
Mailing Address - Fax:
Practice Address - Street 1:9660 WICKER AVE
Practice Address - Street 2:
Practice Address - City:SAINT JOHN
Practice Address - State:IN
Practice Address - Zip Code:46373-9487
Practice Address - Country:US
Practice Address - Phone:219-226-2326
Practice Address - Fax:219-226-2327
Is Sole Proprietor?:No
Enumeration Date:2018-06-18
Last Update Date:2018-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05007706A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist