Provider Demographics
NPI:1497249486
Name:SMITH-KHAN, MICAH ELIZABETH (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MICAH
Middle Name:ELIZABETH
Last Name:SMITH-KHAN
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:MICAH
Other - Middle Name:ELIZABETH
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:330 HUCKLEBERRY LN
Mailing Address - Street 2:
Mailing Address - City:BOULDER CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:95006-9408
Mailing Address - Country:US
Mailing Address - Phone:207-838-2934
Mailing Address - Fax:
Practice Address - Street 1:330 HUCKLEBERRY LN
Practice Address - Street 2:
Practice Address - City:BOULDER CREEK
Practice Address - State:CA
Practice Address - Zip Code:95006-9408
Practice Address - Country:US
Practice Address - Phone:207-838-2934
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-21
Last Update Date:2022-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23475235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist