Provider Demographics
NPI:1073802625
Name:SMITH, GINNY MARISSA (MS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:GINNY
Middle Name:MARISSA
Last Name:SMITH
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1833 MILLENIUM WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1510
Mailing Address - Country:US
Mailing Address - Phone:208-898-1368
Mailing Address - Fax:
Practice Address - Street 1:1833 MILLENIUM WAY
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-1510
Practice Address - Country:US
Practice Address - Phone:208-898-1368
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-05
Last Update Date:2011-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDSLP-1638235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist