Provider Demographics
NPI:1770235095
Name:SMITH, MIA ANNE (CCC-SLP 4335)
Entity Type:Individual
Prefix:
First Name:MIA
Middle Name:ANNE
Last Name:SMITH
Suffix:
Gender:F
Credentials:CCC-SLP 4335
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10617 HOLLYBROOK DR
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70809-4055
Mailing Address - Country:US
Mailing Address - Phone:225-405-1169
Mailing Address - Fax:
Practice Address - Street 1:1100 WEBSTER ST
Practice Address - Street 2:
Practice Address - City:DONALDSONVILLE
Practice Address - State:LA
Practice Address - Zip Code:70346-2754
Practice Address - Country:US
Practice Address - Phone:225-391-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-19
Last Update Date:2022-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA4335235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist