Provider Demographics
NPI:1760402788
Name:SMITH, MARJORIE M (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MARJORIE
Middle Name:M
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 1:9747 SCENIC HWY
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32514-8133
Mailing Address - Country:US
Mailing Address - Phone:850-982-5798
Mailing Address - Fax:850-623-4987
Practice Address - Street 1:4624 SUMMERDALE DR
Practice Address - Street 2:
Practice Address - City:PACE
Practice Address - State:FL
Practice Address - Zip Code:32571-1368
Practice Address - Country:US
Practice Address - Phone:850-994-3456
Practice Address - Fax:850-994-3476
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2013-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA3404235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL882739701Medicaid
FL7639395OtherAETNA NUMBER
FLS2057OtherBCBS NUMBER
FL882739700Medicaid