Provider Demographics
NPI:1962774257
Name:SMITH, MARY B
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:B
Last Name: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:PO BOX 540
Mailing Address - Street 2:RT 60
Mailing Address - City:SINCLAIRVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14782
Mailing Address - Country:US
Mailing Address - Phone:716-962-5155
Mailing Address - Fax:716-962-5976
Practice Address - Street 1:175 MAPLE AVE
Practice Address - Street 2:CASSADAGA ELEMENTARY SCHOOL
Practice Address - City:CASSADAGA
Practice Address - State:NY
Practice Address - Zip Code:14718
Practice Address - Country:US
Practice Address - Phone:716-595-3070
Practice Address - Fax:716-595-2481
Is Sole Proprietor?:No
Enumeration Date:2012-02-01
Last Update Date:2020-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008775-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY008775Medicaid