Provider Demographics
NPI:1033187257
Name:SMITH, GWENNETH P (PT)
Entity type:Individual
Prefix:MS
First Name:GWENNETH
Middle Name:P
Last Name:SMITH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5830 N 19TH AVE
Mailing Address - Street 2:WEST WING
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85015-2494
Mailing Address - Country:US
Mailing Address - Phone:602-249-0202
Mailing Address - Fax:602-249-0004
Practice Address - Street 1:5830 N 19TH AVE
Practice Address - Street 2:WEST WING
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015-2494
Practice Address - Country:US
Practice Address - Phone:602-249-0202
Practice Address - Fax:602-249-0004
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
AZ1947225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist