Provider Demographics
NPI:1013140169
Name:SMITH, COLLEEN K (MA CCC-A)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:K
Last Name:SMITH
Suffix:
Gender:F
Credentials:MA CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1050 ISAAC STREETS DR
Mailing Address - Street 2:SUITE 137
Mailing Address - City:OREGON
Mailing Address - State:OH
Mailing Address - Zip Code:43616-3291
Mailing Address - Country:US
Mailing Address - Phone:419-698-4505
Mailing Address - Fax:419-698-3806
Practice Address - Street 1:1050 ISAAC STREETS DR
Practice Address - Street 2:SUITE 137
Practice Address - City:OREGON
Practice Address - State:OH
Practice Address - Zip Code:43616-3291
Practice Address - Country:US
Practice Address - Phone:419-698-4505
Practice Address - Fax:419-698-3806
Is Sole Proprietor?:No
Enumeration Date:2009-08-24
Last Update Date:2014-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHA. 00703231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0102633Medicaid
OH0102633Medicaid