Provider Demographics
NPI:1720595507
Name:SMITH, TAMARA JANE (SLP)
Entity Type:Individual
Prefix:MS
First Name:TAMARA
Middle Name:JANE
Last Name:SMITH
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:628 LAKE ST NE
Mailing Address - Street 2:
Mailing Address - City:WISE
Mailing Address - State:VA
Mailing Address - Zip Code:24293-7919
Mailing Address - Country:US
Mailing Address - Phone:276-328-8017
Mailing Address - Fax:
Practice Address - Street 1:2945 2ND AVE E
Practice Address - Street 2:
Practice Address - City:BIG STONE GAP
Practice Address - State:VA
Practice Address - Zip Code:24219-3801
Practice Address - Country:US
Practice Address - Phone:276-523-4900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-03
Last Update Date:2018-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2203000329235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA2203000329Medicaid