Provider Demographics
NPI:1356745731
Name:SMITH, DEBRA (HIS)
Entity type:Individual
Prefix:
First Name:DEBRA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 N COMMONS DR STE 200
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60504-7940
Mailing Address - Country:US
Mailing Address - Phone:630-303-5380
Mailing Address - Fax:630-303-5385
Practice Address - Street 1:653 WILL ST
Practice Address - Street 2:
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30224-4236
Practice Address - Country:US
Practice Address - Phone:770-228-5567
Practice Address - Fax:770-228-5567
Is Sole Proprietor?:No
Enumeration Date:2014-10-14
Last Update Date:2021-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAHADS000911237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAHADS000911OtherSTATE OF GEORGIA