Provider Demographics
NPI:1376214239
Name:THURSTON-SMITH, MARY RENEE
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:RENEE
Last Name:THURSTON-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 1:1505 BERRY RD
Mailing Address - Street 2:
Mailing Address - City:GRANBURY
Mailing Address - State:TX
Mailing Address - Zip Code:76049-1114
Mailing Address - Country:US
Mailing Address - Phone:903-861-6951
Mailing Address - Fax:
Practice Address - Street 1:311 DAVIS RD
Practice Address - Street 2:
Practice Address - City:GRANBURY
Practice Address - State:TX
Practice Address - Zip Code:76049-5909
Practice Address - Country:US
Practice Address - Phone:817-408-4768
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-21
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX111756235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist