Provider Demographics
NPI:1538288980
Name:SMITH, MICHELLE ANN (MS CCC)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:ANN
Last Name:SMITH
Suffix:
Gender:F
Credentials:MS CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4253 SW MUNCIE ST
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:33409-0000
Mailing Address - Country:US
Mailing Address - Phone:772-871-2293
Mailing Address - Fax:
Practice Address - Street 1:213 S CONGRESS AVE
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33409-3823
Practice Address - Country:US
Practice Address - Phone:561-640-0013
Practice Address - Fax:561-471-1966
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA3229235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL883504700Medicaid