MEDICARE: SUSAN MARIE SMITH OTR/L

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	01163	IA
2	225X00000X	Occupational Therapist	OT-2444	NV

General Provider Information

NPI Number	:	1174713267
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN MARIE SMITH OTR/L

Provider Business Mailing Address
First Line	:	2110 E FLAMINGO RD STE 314
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89119-5193
Country	:	US
Telephone Number	:	702-947-5200
Fax Number	:

Provider Business Practice Location Address
First Line	:	2110 E FLAMINGO RD STE 314
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89119-5193
Country	:	US
Telephone Number	:	702-947-5200
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/26/2007
Last Update Date	:	10/14/2020

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