Provider Demographics
NPI:1700945896
Name:SMITHERAN, JUDITH R (ST)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:R
Last Name:SMITHERAN
Suffix:
Gender:F
Credentials:ST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:455 SAINT MICHAELS DR
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-7601
Mailing Address - Country:US
Mailing Address - Phone:505-820-5227
Mailing Address - Fax:505-820-5440
Practice Address - Street 1:2025 GALISTEO ST
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-2101
Practice Address - Country:US
Practice Address - Phone:505-820-5702
Practice Address - Fax:505-820-5438
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2007-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM827235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNM00E225OtherBCBS NM
NM69850780Medicaid
10014098OtherLOVELACE
2413409OtherUHC
PROVP16194OtherMOLINA