Provider Demographics
NPI:1174081871
Name:SMITH, KOURTNEY RENEE (DPT, PT)
Entity type:Individual
Prefix:
First Name:KOURTNEY
Middle Name:RENEE
Last Name:SMITH
Suffix:
Gender:F
Credentials:DPT, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9045 US HIGHWAY 31
Mailing Address - Street 2:
Mailing Address - City:BERRIEN SPRINGS
Mailing Address - State:MI
Mailing Address - Zip Code:49103-1804
Mailing Address - Country:US
Mailing Address - Phone:269-861-4547
Mailing Address - Fax:
Practice Address - Street 1:9045 US HIGHWAY 31
Practice Address - Street 2:
Practice Address - City:BERRIEN SPRINGS
Practice Address - State:MI
Practice Address - Zip Code:49103-1804
Practice Address - Country:US
Practice Address - Phone:269-471-7621
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-12
Last Update Date:2019-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA295341225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist