MEDICARE: WANDA RENEE SMITH MA CCCSLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	SLP003773	GA
2	235Z00000X	Speech-Language Pathologist	13318	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1144392796
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WANDA RENEE SMITH MA CCCSLP

Provider Business Mailing Address
First Line	:	1705 COUNTRY GARDEN DR
Second Line	:
City	:	SHELBY
State	:	NC
Zip	:	28150-6162
Country	:	US
Telephone Number	:	770-330-7904
Fax Number	:

Provider Business Practice Location Address
First Line	:	1705 COUNTRY GARDEN DR
Second Line	:
City	:	SHELBY
State	:	NC
Zip	:	28150-6162
Country	:	US
Telephone Number	:	770-330-7904
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/15/2006
Last Update Date	:	10/08/2024

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Directions to “ WANDA RENEE SMITH MA CCCSLP” Practice Location

Language	Start Address	Practice Location

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