Provider Demographics
NPI:1669668802
Name:SMITH, SUSANNAH (MS CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:SUSANNAH
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1676 HOLLAND LAKE DR APT 1203
Mailing Address - Street 2:
Mailing Address - City:WEATHERFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76086-5799
Mailing Address - Country:US
Mailing Address - Phone:501-305-9596
Mailing Address - Fax:
Practice Address - Street 1:1100 LONGHORN DR
Practice Address - Street 2:
Practice Address - City:WEATHERFORD
Practice Address - State:TX
Practice Address - Zip Code:76086-5095
Practice Address - Country:US
Practice Address - Phone:817-598-2800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-21
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2504235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR164945721Medicaid