Provider Demographics
NPI:1265579288
Name:SMITH, MARY (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:847 BERRYHILL CIR
Mailing Address - Street 2:
Mailing Address - City:FRUITLAND PARK
Mailing Address - State:FL
Mailing Address - Zip Code:34731-5287
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:606 S 9TH ST
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-6320
Practice Address - Country:US
Practice Address - Phone:352-805-4404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2023-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA936235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist