Provider Demographics
NPI:1316698251
Name:SMITH, THEOLISHIA VAUGHN
Entity type:Individual
Prefix:
First Name:THEOLISHIA
Middle Name:VAUGHN
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:THEOLISHIA
Other - Middle Name:VAUGHN
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:5160 VALLEYBROOK CIR
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35244-1971
Mailing Address - Country:US
Mailing Address - Phone:205-903-5357
Mailing Address - Fax:
Practice Address - Street 1:5160 VALLEYBROOK CIR
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35244-1971
Practice Address - Country:US
Practice Address - Phone:205-903-5357
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-12
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL3462255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer