Basic Information
| Provider Information | |||||||||
| NPI: | 1700945896 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SMITHERAN | ||||||||
| FirstName: | JUDITH | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | S.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 455 SAINT MICHAELS DR | ||||||||
| Address2: | |||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875057601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058205227 | ||||||||
| FaxNumber: | 5058205440 | ||||||||
| Practice Location | |||||||||
| Address1: | 2025 GALISTEO ST | ||||||||
| Address2: | |||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875052101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058205702 | ||||||||
| FaxNumber: | 5058205438 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2006 | ||||||||
| LastUpdateDate: | 10/31/2007 | ||||||||
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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 | 235Z00000X | 827 | NM | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | NM00E225 | 01 | NM | BCBS NM | OTHER | 69850780 | 05 | NM | MEDICAID | 10014098 | 01 | LOVELACE | OTHER | 2413409 | 01 | UHC | OTHER | PROVP16194 | 01 | MOLINA | OTHER |