Provider Demographics
NPI:1295233385
Name:SMITH, SANDRA O
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:O
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 LORRAINE AVE
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22408-1929
Mailing Address - Country:US
Mailing Address - Phone:540-898-1514
Mailing Address - Fax:540-898-8571
Practice Address - Street 1:400 LORRAINE AVE
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22408-1929
Practice Address - Country:US
Practice Address - Phone:540-898-1514
Practice Address - Fax:540-898-8571
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-24
Last Update Date:2018-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202007548235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty