1811917354 NPI number — MRS. JANICE MARIE DE SMIDT MA CCC-SLP

Table of content: MRS. JANICE MARIE DE SMIDT MA CCC-SLP (NPI 1811917354)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811917354 NPI number — MRS. JANICE MARIE DE SMIDT MA CCC-SLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DE SMIDT
Provider First Name:
JANICE
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MA CCC-SLP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SCHUELLER
Provider Other First Name:
JANICE
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1811917354
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
272 E MERRILL AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FOND DU LAC
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54935-3616
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
920-926-0144
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5595 COUNTY ROAD Z
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEST BEND
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53095-9224
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-306-2100
Provider Business Practice Location Address Fax Number:
262-306-2151
Provider Enumeration Date:
07/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  1074-154 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 01112123 . This is a "ASHA MEMBERSHIP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 42760100 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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