Provider Demographics
NPI:1619578572
Name:SMITH, MADELINE MARIE (AUD)
Entity Type:Individual
Prefix:
First Name:MADELINE
Middle Name:MARIE
Last Name:SMITH
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2525 CHICAGO AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55404-4518
Mailing Address - Country:US
Mailing Address - Phone:763-447-1007
Mailing Address - Fax:
Practice Address - Street 1:2525 CHICAGO AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-4518
Practice Address - Country:US
Practice Address - Phone:612-874-1292
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-05
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10265231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Single Specialty