Provider Demographics
NPI:1346736881
Name:SMITH, CALISSA R (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:CALISSA
Middle Name:R
Last Name:SMITH
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3566 BRIARBROOKE LN
Mailing Address - Street 2:
Mailing Address - City:OAKLAND TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48306-4704
Mailing Address - Country:US
Mailing Address - Phone:586-698-8981
Mailing Address - Fax:
Practice Address - Street 1:3566 BRIARBROOKE LN
Practice Address - Street 2:
Practice Address - City:OAKLAND TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48306-4704
Practice Address - Country:US
Practice Address - Phone:586-698-8981
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-09
Last Update Date:2023-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
235Z00000X
MI235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist