Provider Demographics
NPI:1124197504
Name:SMIDT, VICTORIA S (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:S
Last Name:SMIDT
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 1:16 JUNIPER HILL RD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87122-1911
Mailing Address - Country:US
Mailing Address - Phone:505-263-6004
Mailing Address - Fax:
Practice Address - Street 1:4811 A HARDWARE DRIVE NE
Practice Address - Street 2:ENCHANTMENT SPEECH LANGUAGE PATHOLOGY SERVICES
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-2021
Practice Address - Country:US
Practice Address - Phone:505-263-6004
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2012-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1696235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist