Provider Demographics
NPI:1003309154
Name:SMITH, MICAH JOEL
Entity Type:Individual
Prefix:
First Name:MICAH
Middle Name:JOEL
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:327 S UNIVERSITY AVE APT 4
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72701-5861
Mailing Address - Country:US
Mailing Address - Phone:479-790-0684
Mailing Address - Fax:
Practice Address - Street 1:3801 JOHNSON MILL BLVD # AB
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72704-5297
Practice Address - Country:US
Practice Address - Phone:479-790-0684
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-13
Last Update Date:2018-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR200127235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist