Healthcare Provider Details

I. General information

NPI: 1134732688
Provider Name (Legal Business Name): STEPHEN PATRICK SMITH SA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2020
Last Update Date: 08/25/2020
Certification Date: 08/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 GLENVIEW PL
NAPLES FL
34108-3137
US

IV. Provider business mailing address

8477 S SUNCOAST BLVD
HOMOSASSA FL
34446-5028
US

V. Phone/Fax

Practice location:
  • Phone: 239-591-0011
  • Fax:
Mailing address:
  • Phone: 352-382-7214
  • Fax: 352-382-7781

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number105622778
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSA17989
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: