Provider Demographics
NPI:1174963003
Name:SMITH, ELIZABETH (OTR)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 DEBORAH LEE LN
Mailing Address - Street 2:
Mailing Address - City:NORTH EASTON
Mailing Address - State:MA
Mailing Address - Zip Code:02356-2514
Mailing Address - Country:US
Mailing Address - Phone:774-219-3379
Mailing Address - Fax:
Practice Address - Street 1:1115 W CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-7501
Practice Address - Country:US
Practice Address - Phone:508-580-4691
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-25
Last Update Date:2013-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10902103TE1100X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TE1100XBehavioral Health & Social Service ProvidersPsychologistExercise & Sports
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program