Provider Demographics
NPI:1538315510
Name:SMITH, AMY JO (MACCCA)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:JO
Last Name:SMITH
Suffix:
Gender:F
Credentials:MACCCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:1833 N KINSER PIKE
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47404-1914
Mailing Address - Country:US
Mailing Address - Phone:128-222-8928
Mailing Address - Fax:128-222-8948
Practice Address - Street 1:500 E SPRINGHILL DR
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47802-4439
Practice Address - Country:US
Practice Address - Phone:812-237-0099
Practice Address - Fax:812-237-0097
Is Sole Proprietor?:No
Enumeration Date:2008-08-11
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN23002649A231H00000X
IN17001441A237700000X
IN17001269A237700000X
OH03296237700000X, 237700000X
IL147.000594231H00000X
IN23002476A237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILR03359Medicare PIN