Provider Demographics
NPI:1194151852
Name:PENN-SMITH, TESSA
Entity type:Individual
Prefix:
First Name:TESSA
Middle Name:
Last Name:PENN-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 1:1001 S DIAMOND AVE
Mailing Address - Street 2:
Mailing Address - City:DEMING
Mailing Address - State:NM
Mailing Address - Zip Code:88030-4710
Mailing Address - Country:US
Mailing Address - Phone:575-546-0427
Mailing Address - Fax:
Practice Address - Street 1:310 W ELM ST
Practice Address - Street 2:
Practice Address - City:DEMING
Practice Address - State:NM
Practice Address - Zip Code:88030-4123
Practice Address - Country:US
Practice Address - Phone:575-546-5951
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-25
Last Update Date:2013-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMC-5332235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMC-5332OtherSLP CLINICAL FELLOW