Provider Demographics
NPI:1699744680
Name:SMYTH, MICHELLE RENEE (OT)
Entity type:Individual
Prefix:MR
First Name:MICHELLE
Middle Name:RENEE
Last Name:SMYTH
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3114 CAPSTAN WAY
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80906-8513
Mailing Address - Country:US
Mailing Address - Phone:719-641-7346
Mailing Address - Fax:
Practice Address - Street 1:1650 COCHRANE CIR
Practice Address - Street 2:
Practice Address - City:FORT CARSON
Practice Address - State:CO
Practice Address - Zip Code:80913-4603
Practice Address - Country:US
Practice Address - Phone:719-526-7110
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY-R2835171000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider