Provider Demographics
NPI:1265864367
Name:SMITH, CAROLINE
Entity Type:Individual
Prefix:
First Name:CAROLINE
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:519 POPLAR ST
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29302-2738
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2400 WINCHESTER PL
Practice Address - Street 2:SUITE 102
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29301
Practice Address - Country:US
Practice Address - Phone:864-576-7188
Practice Address - Fax:864-576-8909
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-31
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5293235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC167970135783Medicaid