Provider Demographics
NPI:1235751686
Name:SMITH, DUSTIN (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 CHESTNUT AVE # 2
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07306-1418
Mailing Address - Country:US
Mailing Address - Phone:973-460-6533
Mailing Address - Fax:
Practice Address - Street 1:128 CHESTNUT AVE # 2
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07306-1418
Practice Address - Country:US
Practice Address - Phone:973-460-6533
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-08
Last Update Date:2020-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ41YS01002400235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ41YS01002400OtherNEW JERSEY SPEECH LANGUAGE PATHOLOGY LICENSE
14281343OtherASHA-NATIONAL SPEECH LICENSURE-CERTIFICATE OF CLINICAL COMPETENCE