Provider Demographics
NPI:1699389148
Name:SMITH, ELLEN P (AUD)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:P
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 1:446 OLD NEWPORT BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663-4246
Mailing Address - Country:US
Mailing Address - Phone:949-631-4327
Mailing Address - Fax:949-631-4327
Practice Address - Street 1:446 OLD NEWPORT BLVD STE 100
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-4246
Practice Address - Country:US
Practice Address - Phone:949-631-4327
Practice Address - Fax:949-631-4327
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-02
Last Update Date:2020-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3536231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Single Specialty