Provider Demographics
NPI:1457502288
Name:SMITH, EDWARD GREGORY (MS, CCC-A)
Entity Type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:GREGORY
Last Name:SMITH
Suffix:
Gender:M
Credentials:MS, CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1651 W SUNDANCE RD
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83204-7418
Mailing Address - Country:US
Mailing Address - Phone:208-233-3435
Mailing Address - Fax:208-232-0379
Practice Address - Street 1:921 S 8TH AVE STOP 8116
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83209-0002
Practice Address - Country:US
Practice Address - Phone:208-282-3495
Practice Address - Fax:208-282-4571
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-10
Last Update Date:2008-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDHA-1052231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist