Provider Demographics
NPI:1811055882
Name:SMITH, LAURA SUZANNE (BS - INFANT TODDLER)
Entity type:Individual
Prefix:MS
First Name:LAURA
Middle Name:SUZANNE
Last Name:SMITH
Suffix:
Gender:F
Credentials:BS - INFANT TODDLER
Other - Prefix:MS
Other - First Name:LAURA
Other - Middle Name:SUZANNE
Other - Last Name:JENINGS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 2002
Mailing Address - Street 2:
Mailing Address - City:LYNN HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:32444
Mailing Address - Country:US
Mailing Address - Phone:850-819-1687
Mailing Address - Fax:
Practice Address - Street 1:1201 W 22ND STREET
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405
Practice Address - Country:US
Practice Address - Phone:850-271-0804
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2012-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL811601600103T00000X
222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL811601600Medicaid