Provider Demographics
NPI:1528629524
Name:SMITH, SONYA RENEE
Entity type:Individual
Prefix:MRS
First Name:SONYA
Middle Name:RENEE
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4614 SOUTHCREST DR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40215-2431
Mailing Address - Country:US
Mailing Address - Phone:502-724-9002
Mailing Address - Fax:
Practice Address - Street 1:4614 SOUTHCREST DR
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40215-2431
Practice Address - Country:US
Practice Address - Phone:502-724-9002
Practice Address - Fax:502-375-1984
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-21
Last Update Date:2019-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN0OtherDEVELOPMENTAL THERAPIST