Provider Demographics
NPI:1881019222
Name:SMITH, CONNIE
Entity Type:Individual
Prefix:MRS
First Name:CONNIE
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2707 LISBON ST
Mailing Address - Street 2:
Mailing Address - City:EAST LIVERPOOL
Mailing Address - State:OH
Mailing Address - Zip Code:43920-4053
Mailing Address - Country:US
Mailing Address - Phone:330-383-0596
Mailing Address - Fax:
Practice Address - Street 1:13093 STATE ROUTE 7
Practice Address - Street 2:
Practice Address - City:LISBON
Practice Address - State:OH
Practice Address - Zip Code:44432-9559
Practice Address - Country:US
Practice Address - Phone:330-385-6831
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-21
Last Update Date:2014-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP3708235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHSP3708Medicaid