Provider Demographics
NPI:1992850655
Name:SMITH, PATRICIA CAROL (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:CAROL
Last Name:SMITH
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:437 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:MO
Mailing Address - Zip Code:64755-9377
Mailing Address - Country:US
Mailing Address - Phone:417-214-6300
Mailing Address - Fax:
Practice Address - Street 1:437 N MAIN ST
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:MO
Practice Address - Zip Code:64755-9377
Practice Address - Country:US
Practice Address - Phone:417-214-6300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2010-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004008259235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist