Healthcare Provider Details

I. General information

NPI: 1144416439
Provider Name (Legal Business Name): JEREMY TODD SMITH OTR/L
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2007
Last Update Date: 10/16/2024
Certification Date: 10/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3908 LONG STREET
FORT BRAGG NC
28310-0001
US

IV. Provider business mailing address

3908 LONG STREET
FORT BRAGG NC
28310-0001
US

V. Phone/Fax

Practice location:
  • Phone: 910-907-6916
  • Fax:
Mailing address:
  • Phone: 910-907-6916
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XN1300X
TaxonomyNeurorehabilitation Occupational Therapist
License Number5348
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number5348
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code225XL0004X
TaxonomyLow Vision Occupational Therapist
License Number5348
License Number StateNC
# 4
Primary TaxonomyN
Taxonomy Code225XR0403X
TaxonomyDriving and Community Mobility Occupational Therapist
License Number5348
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: