Provider Demographics
NPI:1992934129
Name:SMITH, WILLIAM RUSSELL
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:RUSSELL
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2625 SW 75TH ST
Mailing Address - Street 2:APT 1201
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32608-8336
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11301 CORPORATE BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32817-8354
Practice Address - Country:US
Practice Address - Phone:877-896-3660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-09
Last Update Date:2009-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA6946224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant