Healthcare Provider Details

I. General information

NPI: 1063878460
Provider Name (Legal Business Name): MARK SMITH OTR/L
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/14/2016
Last Update Date: 01/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4150 CLEMENT ST BLDG 203, GA-32
SAN FRANCISCO CA
94121-1545
US

IV. Provider business mailing address

4150 CLEMENT ST BLDG 203, GA-32
SAN FRANCISCO CA
94121-1545
US

V. Phone/Fax

Practice location:
  • Phone: 415-221-4810
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XM0800X
TaxonomyMental Health Occupational Therapist
License Number14417
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: