1124643846 NPI number — MARY KATE SMITH MA CCC SLP

Table of content: MARY KATE SMITH MA CCC SLP (NPI 1124643846)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124643846 NPI number — MARY KATE SMITH MA CCC SLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMITH
Provider First Name:
MARY
Provider Middle Name:
KATE
Provider Name Prefix Text:
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:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124643846
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/28/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17732 HIGHLAND RD., STE G, BOX 243
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BATON ROUGE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70810-3813
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
225-292-4138
Provider Business Mailing Address Fax Number:
225-636-2940

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18268 PETROLEUM DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BATON ROUGE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70809-6126
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-292-4138
Provider Business Practice Location Address Fax Number:
225-636-2940
Provider Enumeration Date:
06/09/2020

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 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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