Provider Demographics
NPI:1447873294
Name:SMITH, KYLEA MADISON (MS, CF-SLP)
Entity type:Individual
Prefix:
First Name:KYLEA
Middle Name:MADISON
Last Name:SMITH
Suffix:
Gender:F
Credentials:MS, CF-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 W BOIS D ARC AVE
Mailing Address - Street 2:
Mailing Address - City:FORT GIBSON
Mailing Address - State:OK
Mailing Address - Zip Code:74434-8905
Mailing Address - Country:US
Mailing Address - Phone:918-207-5690
Mailing Address - Fax:
Practice Address - Street 1:2220 S WALDRON RD
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-3733
Practice Address - Country:US
Practice Address - Phone:479-434-2371
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-27
Last Update Date:2020-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist