Provider Demographics
NPI:1073864997
Name:SMITH, MALLORIE K (AUD)
Entity Type:Individual
Prefix:
First Name:MALLORIE
Middle Name:K
Last Name:SMITH
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:MALLORIE
Other - Middle Name:K
Other - Last Name:OLSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AUD
Mailing Address - Street 1:1400 E KINCAID ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98274-4127
Mailing Address - Country:US
Mailing Address - Phone:360-814-6451
Mailing Address - Fax:360-445-8592
Practice Address - Street 1:111 S 13TH ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98274-4105
Practice Address - Country:US
Practice Address - Phone:360-336-2178
Practice Address - Fax:360-336-2642
Is Sole Proprietor?:No
Enumeration Date:2012-10-02
Last Update Date:2022-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALD60675180237600000X, 231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
WALD60675180OtherWA STATE LICENSE NUMBER
WA361255OtherWA LABOR & INDUSTRIES