Healthcare Provider Details

I. General information

NPI: 1902016355
Provider Name (Legal Business Name): CATHERINE MARIE SMITH ATC, PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CATHERINE PETERS

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 05/22/2026
Certification Date: 05/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6410 W JEFFERSON BLVD STE 15A
FORT WAYNE IN
46804-6282
US

IV. Provider business mailing address

33900 HARPER AVE STE 104
CLINTON TWP MI
48035-4258
US

V. Phone/Fax

Practice location:
  • Phone: 260-299-7272
  • Fax: 260-299-7273
Mailing address:
  • Phone: 586-477-4689
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number36000666A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number06002616A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: