Healthcare Provider Details

I. General information

NPI: 1699744680
Provider Name (Legal Business Name): MICHELLE RENEE SMYTH OT
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 COCHRANE CIR
FORT CARSON CO
80913-4603
US

IV. Provider business mailing address

3114 CAPSTAN WAY
COLORADO SPRINGS CO
80906-8513
US

V. Phone/Fax

Practice location:
  • Phone: 719-526-7110
  • Fax:
Mailing address:
  • Phone: 719-641-7346
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License NumberKY-R2835
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: