Provider Demographics
NPI:1770220469
Name:SMITH, ABIGAIL (MA CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:ABIGAIL
Middle Name:
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 1:4607 FOX VALLEY DR APT 3A
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-8195
Mailing Address - Country:US
Mailing Address - Phone:810-300-2073
Mailing Address - Fax:
Practice Address - Street 1:5659 STADIUM DR STE 2
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49009-1932
Practice Address - Country:US
Practice Address - Phone:269-372-0436
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-16
Last Update Date:2022-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101007652235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist