Provider Demographics
NPI:1467700302
Name:SMITH, VANESSA CONCORDIA (CCC-SLP)
Entity Type:Individual
Prefix:MISS
First Name:VANESSA
Middle Name:CONCORDIA
Last Name:SMITH
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:308 FORD BUILDING
Mailing Address - Street 2:
Mailing Address - City:UNIVERSITY PARK
Mailing Address - State:PA
Mailing Address - Zip Code:16802
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:308 FORD BUILDING
Practice Address - Street 2:
Practice Address - City:UNIVERSITY PARK
Practice Address - State:PA
Practice Address - Zip Code:16802
Practice Address - Country:US
Practice Address - Phone:413-841-4505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-27
Last Update Date:2012-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL010586235Z00000X
OHSP 10147235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist