Provider Demographics
NPI:1669812236
Name:SMITH, COURTNEY ANNE (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:ANNE
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 1:910 S WINTERHAWK DR
Mailing Address - Street 2:#107
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-3870
Mailing Address - Country:US
Mailing Address - Phone:904-217-3914
Mailing Address - Fax:904-217-3892
Practice Address - Street 1:910 S WINTERHAWK DR
Practice Address - Street 2:#107
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-3870
Practice Address - Country:US
Practice Address - Phone:904-217-3914
Practice Address - Fax:904-217-3892
Is Sole Proprietor?:No
Enumeration Date:2013-06-27
Last Update Date:2016-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA13459235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist