Provider Demographics
NPI:1740946672
Name:SMITH, ELEANOR JACQUELYN (CCC-SLP)
Entity type:Individual
Prefix:
First Name:ELEANOR
Middle Name:JACQUELYN
Last Name:SMITH
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 ASHFORD CIR APT 307
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22401-5067
Mailing Address - Country:US
Mailing Address - Phone:972-935-7435
Mailing Address - Fax:
Practice Address - Street 1:300 PARK HILL DR
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22401-3387
Practice Address - Country:US
Practice Address - Phone:540-368-7300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-15
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202008849235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist