Provider Demographics
NPI:1659488229
Name:SMITH, MARY ANN
Entity Type:Individual
Prefix:
First Name:MARY ANN
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3068 ASHLAND TER
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33761-2001
Mailing Address - Country:US
Mailing Address - Phone:727-787-9243
Mailing Address - Fax:
Practice Address - Street 1:971 VIRGINIA AVE
Practice Address - Street 2:SUITE A
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34683-5235
Practice Address - Country:US
Practice Address - Phone:727-773-2687
Practice Address - Fax:727-773-2742
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA2957235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL890822200Medicaid