Provider Demographics
NPI:1740994169
Name:SMITH, KIERSTEN
Entity type:Individual
Prefix:
First Name:KIERSTEN
Middle Name:
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 1:6103 ARCH STREET PL
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:AL
Mailing Address - Zip Code:35758-5518
Mailing Address - Country:US
Mailing Address - Phone:678-612-0643
Mailing Address - Fax:
Practice Address - Street 1:327 OLD HIGHWAY 431 STE C
Practice Address - Street 2:
Practice Address - City:OWENS CROSS ROADS
Practice Address - State:AL
Practice Address - Zip Code:35763-9474
Practice Address - Country:US
Practice Address - Phone:256-517-9277
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-10
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL5094235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist