Healthcare Provider Details

I. General information

NPI: 1417143835
Provider Name (Legal Business Name): DIANE MARIE SMITH P.T.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2007
Last Update Date: 09/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2650 STOCKTON RD
SAN DIEGO CA
92106-6000
US

IV. Provider business mailing address

18945 FM 2252 STE 115
SAN ANTONIO TX
78266-2797
US

V. Phone/Fax

Practice location:
  • Phone: 619-524-0093
  • Fax: 619-524-6077
Mailing address:
  • Phone: 210-651-0027
  • Fax: 210-651-0029

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number5206
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: