Provider Demographics
NPI:1760716955
Name:SMITH, MARYSA MONICA (CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:MARYSA
Middle Name:MONICA
Last Name:SMITH
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 N FEDERAL HWY STE 220
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33432-2753
Mailing Address - Country:US
Mailing Address - Phone:561-994-6590
Mailing Address - Fax:
Practice Address - Street 1:900 N FEDERAL HWY STE 220
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33432-2753
Practice Address - Country:US
Practice Address - Phone:561-994-6590
Practice Address - Fax:561-994-6690
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-22
Last Update Date:2009-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 5382235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist