Provider Demographics
NPI:1992926117
Name:SMITH, TRISTA LAVONNE (OT)
Entity type:Individual
Prefix:MRS
First Name:TRISTA
Middle Name:LAVONNE
Last Name:SMITH
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 1:196 COUNTY ROAD 213
Mailing Address - Street 2:
Mailing Address - City:CORINTH
Mailing Address - State:MS
Mailing Address - Zip Code:38834-6897
Mailing Address - Country:US
Mailing Address - Phone:662-284-4693
Mailing Address - Fax:
Practice Address - Street 1:835 E POPLAR AVE
Practice Address - Street 2:HWY 64 BYPASS
Practice Address - City:SELMER
Practice Address - State:TN
Practice Address - Zip Code:38375-1832
Practice Address - Country:US
Practice Address - Phone:731-645-3201
Practice Address - Fax:731-645-4912
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNOT0000003028225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist