Provider Demographics
NPI:1912330838
Name:SMITH, OLIVIA (MED)
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 SERENITY FARMS RD
Mailing Address - Street 2:
Mailing Address - City:WOODBINE
Mailing Address - State:GA
Mailing Address - Zip Code:31569-4440
Mailing Address - Country:US
Mailing Address - Phone:912-230-0024
Mailing Address - Fax:912-576-5182
Practice Address - Street 1:24 SERENITY FARMS RD
Practice Address - Street 2:
Practice Address - City:WOODBINE
Practice Address - State:GA
Practice Address - Zip Code:31569-4440
Practice Address - Country:US
Practice Address - Phone:912-230-0024
Practice Address - Fax:912-576-5182
Is Sole Proprietor?:No
Enumeration Date:2013-08-14
Last Update Date:2013-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP008233235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist