Provider Demographics
NPI:1669884813
Name:SMITH, MARY KATHRYN
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:KATHRYN
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 1:1441 NEW ENGLAND RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:26181
Mailing Address - Country:US
Mailing Address - Phone:740-434-3635
Mailing Address - Fax:
Practice Address - Street 1:300 PIKE ST
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:OH
Practice Address - Zip Code:45750-3372
Practice Address - Country:US
Practice Address - Phone:740-374-6514
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-22
Last Update Date:2017-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHBG1019507235Z00000X
OHSP. 6642235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist