Provider Demographics
NPI:1164492534
Name:SMITH, BETTY MAE (RPT)
Entity type:Individual
Prefix:MRS
First Name:BETTY
Middle Name:MAE
Last Name:SMITH
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:MS
Other - First Name:BETTY
Other - Middle Name:MAE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:14410 TATUM COURT
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701
Mailing Address - Country:US
Mailing Address - Phone:605-343-0543
Mailing Address - Fax:605-385-3329
Practice Address - Street 1:2900 DOOLITTLE DR
Practice Address - Street 2:
Practice Address - City:ELLSWORTH AFB
Practice Address - State:SD
Practice Address - Zip Code:57706-4821
Practice Address - Country:US
Practice Address - Phone:605-385-3676
Practice Address - Fax:605-385-3329
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1141225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1141OtherPHYSICAL THERAPY LICENSE