Provider Demographics
NPI:1689648289
Name:SMITH, HOLLY ROUTH (MA, CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:HOLLY
Middle Name:ROUTH
Last Name:SMITH
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 CARPENTER AVE
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28115-2512
Mailing Address - Country:US
Mailing Address - Phone:704-880-1476
Mailing Address - Fax:
Practice Address - Street 1:510 CARPENTER AVE
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28115-2512
Practice Address - Country:US
Practice Address - Phone:704-880-1476
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6812235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7412424Medicaid