Provider Demographics
NPI:1861505513
Name:SMITH, RANDALL D (MED, CCC-SLP)
Entity Type:Individual
Prefix:MR
First Name:RANDALL
Middle Name:D
Last Name:SMITH
Suffix:
Gender:M
Credentials:MED, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:3110 S WADSWORTH BLVD
Mailing Address - Street 2:STE 107
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80227-4805
Mailing Address - Country:US
Mailing Address - Phone:303-988-7299
Mailing Address - Fax:303-988-8502
Practice Address - Street 1:3110 S WADSWORTH BLVD
Practice Address - Street 2:STE 107
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80227-4805
Practice Address - Country:US
Practice Address - Phone:303-988-7299
Practice Address - Fax:303-988-8502
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2012-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
235Z00000X
COCO HAD #80237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist