Provider Demographics
NPI:1861894420
Name:SMITH, IESHA BRIDGES (OTR/L)
Entity type:Individual
Prefix:
First Name:IESHA
Middle Name:BRIDGES
Last Name:SMITH
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:170 E GRIFFITH ST APT 209
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39201-1396
Mailing Address - Country:US
Mailing Address - Phone:404-991-0367
Mailing Address - Fax:
Practice Address - Street 1:170 E GRIFFITH ST APT 209
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39201-1396
Practice Address - Country:US
Practice Address - Phone:404-991-0367
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-25
Last Update Date:2014-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSOT2921225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics