Provider Demographics
NPI:1144729914
Name:SMITH, CODY WADE (MS, CCC-SLP)
Entity type:Individual
Prefix:MR
First Name:CODY
Middle Name:WADE
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 1:133 HILLCREST DR
Mailing Address - Street 2:
Mailing Address - City:BARDWELL
Mailing Address - State:KY
Mailing Address - Zip Code:42023-8574
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4747 ALBEN BARKLEY DR
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42001-6789
Practice Address - Country:US
Practice Address - Phone:270-444-9661
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-07
Last Update Date:2018-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY173513235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist