Provider Demographics
NPI:1205166949
Name:SMOCK, PAMELA MARIE (MA, CCC-SLP)
Entity type:Individual
Prefix:MS
First Name:PAMELA
Middle Name:MARIE
Last Name:SMOCK
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1350 N TODD DR
Mailing Address - Street 2:
Mailing Address - City:SCOTTSBURG
Mailing Address - State:IN
Mailing Address - Zip Code:47170-7755
Mailing Address - Country:US
Mailing Address - Phone:812-752-5663
Mailing Address - Fax:
Practice Address - Street 1:1350 N TODD DR
Practice Address - Street 2:
Practice Address - City:SCOTTSBURG
Practice Address - State:IN
Practice Address - Zip Code:47170-7755
Practice Address - Country:US
Practice Address - Phone:812-752-5663
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-31
Last Update Date:2009-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22002932A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist