Healthcare Provider Details

I. General information

NPI: 1861894420
Provider Name (Legal Business Name): IESHA BRIDGES SMITH OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2014
Last Update Date: 09/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

170 E GRIFFITH ST APT 209
JACKSON MS
39201-1396
US

IV. Provider business mailing address

170 E GRIFFITH ST APT 209
JACKSON MS
39201-1396
US

V. Phone/Fax

Practice location:
  • Phone: 404-991-0367
  • Fax:
Mailing address:
  • Phone: 404-991-0367
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOT2921
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: