Healthcare Provider Details

I. General information

NPI: 1861505513
Provider Name (Legal Business Name): RANDALL D. SMITH M.ED., CCC-SLP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2006
Last Update Date: 11/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3110 S WADSWORTH BLVD STE 107
LAKEWOOD CO
80227-4805
US

IV. Provider business mailing address

3110 S WADSWORTH BLVD STE 107
LAKEWOOD CO
80227-4805
US

V. Phone/Fax

Practice location:
  • Phone: 303-988-7299
  • Fax: 303-988-8502
Mailing address:
  • Phone: 303-988-7299
  • Fax: 303-988-8502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License NumberCO HAD #80
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: