Provider Demographics
NPI:1548666068
Name:SMITH, STEPHEN (LMT)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13140 KANSAS AVE APT A1-101
Mailing Address - Street 2:
Mailing Address - City:BONNER SPRINGS
Mailing Address - State:KS
Mailing Address - Zip Code:66012-9386
Mailing Address - Country:US
Mailing Address - Phone:913-333-8085
Mailing Address - Fax:
Practice Address - Street 1:626 E 4TH ST
Practice Address - Street 2:
Practice Address - City:TONGANOXIE
Practice Address - State:KS
Practice Address - Zip Code:66086-9219
Practice Address - Country:US
Practice Address - Phone:913-333-8085
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-11
Last Update Date:2014-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist