Healthcare Provider Details

I. General information

NPI: 1144339409
Provider Name (Legal Business Name): MARY KATHLEEN SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 08/13/2021
Certification Date: 08/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 BRADEN AVE
SARASOTA FL
34243-2001
US

IV. Provider business mailing address

350 BRADEN AVE
SARASOTA FL
34243-2001
US

V. Phone/Fax

Practice location:
  • Phone: 941-355-7637
  • Fax: 941-444-2271
Mailing address:
  • Phone: 941-355-7637
  • Fax: 941-444-2271

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSA6063
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: