Provider Demographics
NPI:1215349238
Name:SMITH, LUCY DIANE (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:LUCY
Middle Name:DIANE
Last Name:SMITH
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:713 MORRIS TULLOS DR
Mailing Address - Street 2:
Mailing Address - City:MORTON
Mailing Address - State:MS
Mailing Address - Zip Code:39117-3110
Mailing Address - Country:US
Mailing Address - Phone:601-606-8006
Mailing Address - Fax:
Practice Address - Street 1:4805 W 4TH ST
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-1019
Practice Address - Country:US
Practice Address - Phone:601-270-6968
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-25
Last Update Date:2019-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS3637235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist