Provider Demographics
NPI:1588075121
Name:SMITLEY, MATTHEW CHARLEW (DAT, LAT, ATC)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:CHARLEW
Last Name:SMITLEY
Suffix:
Gender:M
Credentials:DAT, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 OPAL BROOK DR
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTON
Mailing Address - State:TN
Mailing Address - Zip Code:37643-7462
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:875 PERIMETER DR # MS 2401
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83844-7462
Practice Address - Country:US
Practice Address - Phone:208-885-0349
Practice Address - Fax:208-885-5929
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-16
Last Update Date:2020-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLAT-25182255A2300X
IDAT-6422255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer