Basic Information
| Provider Information | |||||||||
| NPI: | 1245966027 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | MADELINE | ||||||||
| MiddleName: | MARIE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3920 LOVERS LN | ||||||||
| Address2: | |||||||||
| City: | RAVENNA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 442664200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3306731347 | ||||||||
| FaxNumber: | 3306783677 | ||||||||
| Practice Location | |||||||||
| Address1: | 3920 LOVERS LN | ||||||||
| Address2: | |||||||||
| City: | RAVENNA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 442664200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3306731347 | ||||||||
| FaxNumber: | 3306783677 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2022 | ||||||||
| LastUpdateDate: | 07/25/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
No ID Information.