Provider Demographics
NPI:1295350981
Name:SMITH, KALEB DELTON (DPT)
Entity type:Individual
Prefix:
First Name:KALEB
Middle Name:DELTON
Last Name:SMITH
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:802 LAKELAND DR APT 245
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4622
Mailing Address - Country:US
Mailing Address - Phone:601-580-2775
Mailing Address - Fax:
Practice Address - Street 1:117 BO BO DR
Practice Address - Street 2:
Practice Address - City:CRYSTAL SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39059-2741
Practice Address - Country:US
Practice Address - Phone:601-892-6330
Practice Address - Fax:601-892-6331
Is Sole Proprietor?:No
Enumeration Date:2020-06-09
Last Update Date:2020-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT6894225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist