Basic Information
| Provider Information | |||||||||
| NPI: | 1013140169 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | COLLEEN | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | M.A. CCC-A | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1050 ISAAC STREETS DR | ||||||||
| Address2: | SUITE 137 | ||||||||
| City: | OREGON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436163291 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4196984505 | ||||||||
| FaxNumber: | 4196983806 | ||||||||
| Practice Location | |||||||||
| Address1: | 1050 ISAAC STREETS DR | ||||||||
| Address2: | SUITE 137 | ||||||||
| City: | OREGON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436163291 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4196984505 | ||||||||
| FaxNumber: | 4196983806 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2009 | ||||||||
| LastUpdateDate: | 12/18/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | A. 00703 | OH | Y | Speech, Language and Hearing Service Providers | Audiologist |
ID Information
| ID | Type | State | Issuer | Description | 0102633 | 05 | OH | MEDICAID |