Provider Demographics
NPI:1861869026
Name:SMITH, ADAM (PT, DPT, CSCS)
Entity type:Individual
Prefix:
First Name:ADAM
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:PT, DPT, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2025 E WYNDHAM HILL DR NE
Mailing Address - Street 2:APT 204
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49505-7106
Mailing Address - Country:US
Mailing Address - Phone:517-648-8869
Mailing Address - Fax:
Practice Address - Street 1:2885 10 MILE RD NE
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:MI
Practice Address - Zip Code:49341-9177
Practice Address - Country:US
Practice Address - Phone:616-866-6300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-24
Last Update Date:2016-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA42941225100000X
MI5501017646225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist