Provider Demographics
NPI:1053712596
Name:SMITH, RAYMOND WALLER (LMT)
Entity type:Individual
Prefix:MR
First Name:RAYMOND
Middle Name:WALLER
Last Name:SMITH
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1620 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:MO
Mailing Address - Zip Code:64085-2610
Mailing Address - Country:US
Mailing Address - Phone:816-682-5819
Mailing Address - Fax:
Practice Address - Street 1:810 E MAIN ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:MO
Practice Address - Zip Code:64085-1908
Practice Address - Country:US
Practice Address - Phone:816-682-5819
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-15
Last Update Date:2014-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004011221225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist