MEDICARE: DR. CAROL JEAN SMITH PT, DPT

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	225100000X	Physical Therapist	1193873	TX

General Provider Information

NPI Number	:	1467782656
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CAROL JEAN SMITH PT, DPT

Provider Business Mailing Address
First Line	:	4120 HERITAGE TRACE PKWY
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76244-5308
Country	:	US
Telephone Number	:	817-741-7585
Fax Number	:	817-741-7587

Provider Business Practice Location Address
First Line	:	4120 HERITAGE TRACE PKWY
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76244-5308
Country	:	US
Telephone Number	:	817-741-7585
Fax Number	:	817-741-7587

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

Provider Enumeration Date	:	01/11/2010
Last Update Date	:	01/11/2010

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