Provider Demographics
NPI:1649872490
Name:SMITH, PATRICIA (PT, CCC/SLP)
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:PT, 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:PO BOX 174
Mailing Address - Street 2:
Mailing Address - City:GLENBROOK
Mailing Address - State:NV
Mailing Address - Zip Code:89413-0174
Mailing Address - Country:US
Mailing Address - Phone:805-479-2769
Mailing Address - Fax:
Practice Address - Street 1:1639 LOGAN CREEK
Practice Address - Street 2:
Practice Address - City:GLENBROOK
Practice Address - State:NV
Practice Address - Zip Code:89413
Practice Address - Country:US
Practice Address - Phone:805-479-2769
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-16
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT-6691225100000X
CASP-13938235Z00000X
NVSP-2088235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist