MEDICARE: CARLTON SMITH JR. OTR/L

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	31007737A	IN

General Provider Information

NPI Number	:	1740029446
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARLTON SMITH JR. OTR/L

Provider Business Mailing Address
First Line	:	922 HARBOR AVE
Second Line	:
City	:	SOUTH BEND
State	:	IN
Zip	:	46615-3426
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	922 HARBOR AVE
Second Line	:
City	:	SOUTH BEND
State	:	IN
Zip	:	46615-3426
Country	:	US
Telephone Number	:	574-315-6093
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/22/2024
Last Update Date	:	05/07/2025

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