Provider Demographics
NPI:1225669856
Name:SMITH-TAVARIS, KASHALA (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KASHALA
Middle Name:
Last Name:SMITH-TAVARIS
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:KASHALA
Other - Middle Name:
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS CCC-SLP
Mailing Address - Street 1:60 KATONA DR STE 24
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06824-3544
Mailing Address - Country:US
Mailing Address - Phone:203-567-0142
Mailing Address - Fax:866-608-3856
Practice Address - Street 1:60 KATONA DR STE 24
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06824-3544
Practice Address - Country:US
Practice Address - Phone:203-576-0142
Practice Address - Fax:866-608-3856
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-02
Last Update Date:2020-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003820235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT003820OtherCT LICENSE IN SPEECH LANGUAGE PATHOLOGY