Provider Demographics
NPI:1669620894
Name:SMITH, EDDIE BULLER (MEDCCCSLP)
Entity type:Individual
Prefix:
First Name:EDDIE
Middle Name:BULLER
Last Name:SMITH
Suffix:
Gender:M
Credentials:MEDCCCSLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:216 N JOHN REDDITT DR
Mailing Address - Street 2:
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75904-2620
Mailing Address - Country:US
Mailing Address - Phone:936-632-2107
Mailing Address - Fax:
Practice Address - Street 1:216 N JOHN REDDITT DR
Practice Address - Street 2:
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75904-2620
Practice Address - Country:US
Practice Address - Phone:936-632-2107
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-29
Last Update Date:2008-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX18200235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist