Provider Demographics
NPI:1386390292
Name:SMITH, ROBERT THOMAS II (PTA)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:THOMAS
Last Name:SMITH
Suffix:II
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 N COURTENAY PKWY APT 230
Mailing Address - Street 2:
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32953-4696
Mailing Address - Country:US
Mailing Address - Phone:321-591-8240
Mailing Address - Fax:
Practice Address - Street 1:2080 W EAU GALLIE BLVD STE A
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-3185
Practice Address - Country:US
Practice Address - Phone:407-694-3603
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-01
Last Update Date:2022-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA30489225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant