Basic Information
| Provider Information | |||||||||
| NPI: | 1134197494 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITLEY | ||||||||
| FirstName: | SUZANNE | ||||||||
| MiddleName: | L. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4841 MONROE ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436234385 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4194752535 | ||||||||
| FaxNumber: | 4194750881 | ||||||||
| Practice Location | |||||||||
| Address1: | 4841 MONROE ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436234385 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4194752535 | ||||||||
| FaxNumber: | 4194750881 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/10/2006 | ||||||||
| LastUpdateDate: | 10/19/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 3744 | OH | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 0675014 | 05 | OH | MEDICAID |