Provider Demographics
NPI:1053439745
Name:SMITH, KRISTINE ANN (OT)
Entity type:Individual
Prefix:MRS
First Name:KRISTINE
Middle Name:ANN
Last Name:SMITH
Suffix:
Gender:F
Credentials:OT
Other - Prefix:MRS
Other - First Name:KRISTINE
Other - Middle Name:ANN
Other - Last Name:VIOLETTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OT
Mailing Address - Street 1:2285 E APPLEBY RD
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85298-9307
Mailing Address - Country:US
Mailing Address - Phone:602-579-1917
Mailing Address - Fax:480-659-2693
Practice Address - Street 1:4902 S VAL VISTA DR
Practice Address - Street 2:SUITE B102
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85298-7325
Practice Address - Country:US
Practice Address - Phone:480-855-8866
Practice Address - Fax:480-855-8867
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0718225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ0718OtherSTATE LICENSE
AZ133851Medicaid