Provider Demographics
NPI:1861157893
Name:SMITH, KATHRYN LAND (PT, DPT)
Entity type:Individual
Prefix:DR
First Name:KATHRYN
Middle Name:LAND
Last Name:SMITH
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1056 COPPER CREEK DR
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114-6897
Mailing Address - Country:US
Mailing Address - Phone:229-567-7783
Mailing Address - Fax:
Practice Address - Street 1:9880 HICKORY FLAT HWY
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-3081
Practice Address - Country:US
Practice Address - Phone:770-687-2542
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-04
Last Update Date:2021-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT015668225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAPT015668OtherGEORGIA PROFESSIONAL LICENSING BOARD