Provider Demographics
NPI:1346040664
Name:SMITH, SCOTT KEITH (CMT)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:KEITH
Last Name:SMITH
Suffix:
Gender:
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1483 LOMA SOLA CT
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-2849
Mailing Address - Country:US
Mailing Address - Phone:213-884-3619
Mailing Address - Fax:
Practice Address - Street 1:1483 LOMA SOLA CT
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-2849
Practice Address - Country:US
Practice Address - Phone:213-884-3619
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-17
Last Update Date:2025-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225700000X
CA40374225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist