Provider Demographics
NPI:1588365126
Name:SMITH, BRIAN CLARK (PT, DPT, NCS)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:CLARK
Last Name:SMITH
Suffix:
Gender:M
Credentials:PT, DPT, NCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5206 WILLOW MILL DR
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30068-4758
Mailing Address - Country:US
Mailing Address - Phone:678-662-7775
Mailing Address - Fax:
Practice Address - Street 1:5206 WILLOW MILL DR
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30068-4758
Practice Address - Country:US
Practice Address - Phone:678-662-7775
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-10
Last Update Date:2023-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT009718225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist