Provider Demographics
NPI:1861732133
Name:SMITH, CANDICE RENE (PTA)
Entity type:Individual
Prefix:
First Name:CANDICE
Middle Name:RENE
Last Name:SMITH
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9751 W 85TH ST
Mailing Address - Street 2:APT A
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66212-4516
Mailing Address - Country:US
Mailing Address - Phone:816-582-5815
Mailing Address - Fax:
Practice Address - Street 1:9751 W 85TH ST
Practice Address - Street 2:APT A
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66212-4516
Practice Address - Country:US
Practice Address - Phone:816-582-5815
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-25
Last Update Date:2013-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS14-02467225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant