Provider Demographics
NPI:1144981929
Name:SMITH, WILLIAM BRADLEY
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:BRADLEY
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 1:1015 RIVER HAVEN CIR APT J
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29412-4124
Mailing Address - Country:US
Mailing Address - Phone:580-326-4218
Mailing Address - Fax:
Practice Address - Street 1:921 TOWN CENTER DR
Practice Address - Street 2:
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-8311
Practice Address - Country:US
Practice Address - Phone:386-218-0092
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-04
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL22611225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL22611Medicaid