MEDICARE: KATHLEEN 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	2212	CA

General Provider Information

NPI Number	:	1760841175
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHLEEN MARIE SMITH OTR/L

Provider Business Mailing Address
First Line	:	215 11TH ST # 2
Second Line	:
City	:	SEAL BEACH
State	:	CA
Zip	:	90740-6426
Country	:	US
Telephone Number	:	562-999-6830
Fax Number	:

Provider Business Practice Location Address
First Line	:	3294 SANTA FE AVE
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90810-2408
Country	:	US
Telephone Number	:	562-424-0757
Fax Number	:

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

Provider Enumeration Date	:	02/12/2016
Last Update Date	:	02/12/2016

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