Provider Demographics
NPI:1740977040
Name:SMITH, MCKENNA (MA, CCC-SLP)
Entity type:Individual
Prefix:
First Name:MCKENNA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3560 FOUNTAIN CIR APT 106
Mailing Address - Street 2:
Mailing Address - City:AUBURN HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48326-3986
Mailing Address - Country:US
Mailing Address - Phone:309-642-9812
Mailing Address - Fax:
Practice Address - Street 1:24125 DRAKE RD
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48335-3108
Practice Address - Country:US
Practice Address - Phone:248-238-9772
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-18
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7152000332235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist