Provider Demographics
NPI:1770820227
Name:SMITH, TIANA NIKOLE (MA CCC SLP)
Entity Type:Individual
Prefix:MRS
First Name:TIANA
Middle Name:NIKOLE
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 1:1616 WILSON MANOR CIR
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30045-3749
Mailing Address - Country:US
Mailing Address - Phone:330-958-1882
Mailing Address - Fax:
Practice Address - Street 1:1616 WILSON MANOR CIR
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30045-3749
Practice Address - Country:US
Practice Address - Phone:330-958-1882
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-03
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP.10580235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHCMS-855Medicare PIN