Provider Demographics
NPI:1023233376
Name:SMITH FOWLER, GLENDA AUDREY (AUD)
Entity type:Individual
Prefix:
First Name:GLENDA
Middle Name:AUDREY
Last Name:SMITH FOWLER
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2611 PRINGLE RD SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-1533
Mailing Address - Country:US
Mailing Address - Phone:503-385-4709
Mailing Address - Fax:
Practice Address - Street 1:2611 PRINGLE RD SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-1533
Practice Address - Country:US
Practice Address - Phone:503-385-4709
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-13
Last Update Date:2011-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR297154Medicaid