Provider Demographics
NPI:1366957029
Name:SMITH, MARY DANIEL
Entity type:Individual
Prefix:
First Name:MARY DANIEL
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3000 BUSINESS PARK CIR STE 400
Mailing Address - Street 2:
Mailing Address - City:GOODLETTSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37072-3185
Mailing Address - Country:US
Mailing Address - Phone:615-855-2285
Mailing Address - Fax:
Practice Address - Street 1:3000 BUSINESS PARK CIR STE 400
Practice Address - Street 2:
Practice Address - City:GOODLETTSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37072-3185
Practice Address - Country:US
Practice Address - Phone:615-855-2285
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-04
Last Update Date:2017-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN5999235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN14110886OtherAMERICAN SPEECH HEARING ASSOCIATION
TN5999OtherTENNESSEE BOARD OF HEALTH