Provider Demographics
NPI:1457960098
Name:SMITH, DERRICK GARNER (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:DERRICK
Middle Name:GARNER
Last Name:SMITH
Suffix:
Gender:
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 1:9191 DALTON CIR
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CA
Mailing Address - Zip Code:92683-6517
Mailing Address - Country:US
Mailing Address - Phone:714-902-9171
Mailing Address - Fax:
Practice Address - Street 1:24422 AVENIDA DE LA CARLOTA STE 190
Practice Address - Street 2:
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-3634
Practice Address - Country:US
Practice Address - Phone:949-340-6937
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-29
Last Update Date:2025-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP32594235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist