Provider Demographics
NPI:1295732915
Name:SMITH, AUDRA (PHYSICAL THERAPIST)
Entity type:Individual
Prefix:
First Name:AUDRA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17904 GEORGIA AVENUE
Mailing Address - Street 2:SUITE 215
Mailing Address - City:OLNEY
Mailing Address - State:MD
Mailing Address - Zip Code:20832
Mailing Address - Country:US
Mailing Address - Phone:301-232-1050
Mailing Address - Fax:310-232-1044
Practice Address - Street 1:17904 GEORGIA AVENUE
Practice Address - Street 2:SUITE 215
Practice Address - City:OLNEY
Practice Address - State:MD
Practice Address - Zip Code:20832
Practice Address - Country:US
Practice Address - Phone:301-232-1050
Practice Address - Fax:301-232-1044
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2013-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD20269174400000X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD20269OtherLICENCE