Provider Demographics
NPI:1558532226
Name:SMITH, CHARLENE DEONNE (MS,CCC-A)
Entity Type:Individual
Prefix:MRS
First Name:CHARLENE
Middle Name:DEONNE
Last Name:SMITH
Suffix:
Gender:F
Credentials:MS,CCC-A
Other - Prefix:
Other - First Name:CHARLENE
Other - Middle Name:DEONNE
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS,CCC-A
Mailing Address - Street 1:107 FRONT ST
Mailing Address - Street 2:SUITE 2141
Mailing Address - City:VIDALIA
Mailing Address - State:LA
Mailing Address - Zip Code:71373-2836
Mailing Address - Country:US
Mailing Address - Phone:318-336-2214
Mailing Address - Fax:318-336-6069
Practice Address - Street 1:107 FRONT STREET
Practice Address - Street 2:SUITE 2141
Practice Address - City:VIDALIA
Practice Address - State:LA
Practice Address - Zip Code:71373
Practice Address - Country:US
Practice Address - Phone:318-336-2214
Practice Address - Fax:318-336-6069
Is Sole Proprietor?:No
Enumeration Date:2008-03-20
Last Update Date:2008-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA4961237600000X
MSA2533237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
12052628OtherASHA
LA4961OtherLOUISIANA LICENSE
MSA2533OtherMISSISSIPPI LICENSE