Provider Demographics
NPI:1275867020
Name:SMITH, THERESA MARIE (MS)
Entity Type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:MARIE
Last Name:SMITH
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:745 MAIN ST APT 7
Mailing Address - Street 2:
Mailing Address - City:KEWASKUM
Mailing Address - State:WI
Mailing Address - Zip Code:53040-9275
Mailing Address - Country:US
Mailing Address - Phone:262-337-3328
Mailing Address - Fax:
Practice Address - Street 1:620 SCHOENHAAR DR
Practice Address - Street 2:
Practice Address - City:WEST BEND
Practice Address - State:WI
Practice Address - Zip Code:53090-2649
Practice Address - Country:US
Practice Address - Phone:262-306-8450
Practice Address - Fax:262-306-8451
Is Sole Proprietor?:No
Enumeration Date:2009-09-28
Last Update Date:2009-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3302-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist