Provider Demographics
NPI:1003142175
Name:SMITH, MEGAN (SLP)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7173A MOAK RD
Mailing Address - Street 2:
Mailing Address - City:SUMMIT
Mailing Address - State:MS
Mailing Address - Zip Code:39666-7505
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3457 S GREENSBURG RD
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:MS
Practice Address - Zip Code:39645-9580
Practice Address - Country:US
Practice Address - Phone:601-657-4364
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-26
Last Update Date:2009-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS12133854235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist