Provider Demographics
NPI:1306967682
Name:SMITH, MICHAEL WILLIAM GAUVIN (MS, CCC-SLP)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:WILLIAM GAUVIN
Last Name:SMITH
Suffix:
Gender:M
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 1:30 PIEDMONT AVE
Mailing Address - Street 2:
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02451-3013
Mailing Address - Country:US
Mailing Address - Phone:781-367-0841
Mailing Address - Fax:
Practice Address - Street 1:30 PIEDMONT AVE
Practice Address - Street 2:
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02451-3013
Practice Address - Country:US
Practice Address - Phone:781-367-0841
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2007-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA12020466235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA5731OtherBLUE CROSS AND BLUE SHIEL