Healthcare Provider Details

I. General information

NPI: 1356721583
Provider Name (Legal Business Name): SEAN SMITH DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2015
Last Update Date: 01/23/2023
Certification Date: 01/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 MEMORIAL DR
BERLIN WI
54923-1243
US

IV. Provider business mailing address

225 MEMORIAL DR
BERLIN WI
54923-1243
US

V. Phone/Fax

Practice location:
  • Phone: 920-361-5534
  • Fax: 920-361-5910
Mailing address:
  • Phone: 920-361-5534
  • Fax: 920-361-5910

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1260610
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number15303
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: