Provider Demographics
NPI:1346098480
Name:SMITH, EDWARD L SR
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:L
Last Name:SMITH
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9127 CORPORATE DR
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-1243
Mailing Address - Country:US
Mailing Address - Phone:662-812-3685
Mailing Address - Fax:
Practice Address - Street 1:9127 CORPORATE DR
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-1243
Practice Address - Country:US
Practice Address - Phone:662-812-3685
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-13
Last Update Date:2024-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172A00000X
MSS-2758235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No172A00000XOther Service ProvidersDriver