Provider Demographics
NPI:1144392796
Name:SMITH, WANDA RENEE (MA CCCSLP)
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:RENEE
Last Name:SMITH
Suffix:
Gender:F
Credentials:MA CCCSLP
Other - Prefix:
Other - First Name:WANDA
Other - Middle Name:RENEE
Other - Last Name:WHITE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1705 COUNTRY GARDEN DR
Mailing Address - Street 2:
Mailing Address - City:SHELBY
Mailing Address - State:NC
Mailing Address - Zip Code:28150-6162
Mailing Address - Country:US
Mailing Address - Phone:770-330-7904
Mailing Address - Fax:
Practice Address - Street 1:1705 COUNTRY GARDEN DR
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:NC
Practice Address - Zip Code:28150-6162
Practice Address - Country:US
Practice Address - Phone:770-330-7904
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2019-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC13318235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA840702411AMedicaid