Provider Demographics
NPI:1861975419
Name:SMITH, CARMEN RAE (OTD, OTR/L)
Entity type:Individual
Prefix:
First Name:CARMEN
Middle Name:RAE
Last Name:SMITH
Suffix:
Gender:F
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1415 THOMAS AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92109-4336
Mailing Address - Country:US
Mailing Address - Phone:480-244-6058
Mailing Address - Fax:
Practice Address - Street 1:2521 WINDWARD WAY
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91914-4526
Practice Address - Country:US
Practice Address - Phone:619-621-5266
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-10
Last Update Date:2020-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19183225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics