Provider Demographics
NPI:1811917354
Name:DE SMIDT, JANICE MARIE (MA CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:JANICE
Middle Name:MARIE
Last Name:DE SMIDT
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:MISS
Other - First Name:JANICE
Other - Middle Name:MARIE
Other - Last Name:SCHUELLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:272 E MERRILL AVE
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-3616
Mailing Address - Country:US
Mailing Address - Phone:920-926-0144
Mailing Address - Fax:
Practice Address - Street 1:5595 COUNTY ROAD Z
Practice Address - Street 2:
Practice Address - City:WEST BEND
Practice Address - State:WI
Practice Address - Zip Code:53095-9224
Practice Address - Country:US
Practice Address - Phone:262-306-2100
Practice Address - Fax:262-306-2151
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1074-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
01112123OtherASHA MEMBERSHIP
WI42760100Medicaid