Provider Demographics
NPI:1801186226
Name:BLACK-SMITH, MEGAN E (SLP, MS, CCC)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:E
Last Name:BLACK-SMITH
Suffix:
Gender:F
Credentials:SLP, MS, CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1325 E BROWNING AVE
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84105-2601
Mailing Address - Country:US
Mailing Address - Phone:480-204-1353
Mailing Address - Fax:
Practice Address - Street 1:1325 E BROWNING AVE
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84105-2601
Practice Address - Country:US
Practice Address - Phone:480-204-1353
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-19
Last Update Date:2021-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
AZSLPA71962355S0801X
UT12104020-4102235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT12104020-4102OtherSTATE OF UTAH DEPARTMENT OF COMMERCE SLP LICENSE
AZSLPA7196OtherSTATE LICENSE NUMBER