Basic Information
| Provider Information | |||||||||
| NPI: | 1336479740 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | COLLEEN | ||||||||
| MiddleName: | F | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MA CLINICAL PSYCHOLO | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | O'PELL-RIDDEL | ||||||||
| OtherFirstName: | COLLEEN | ||||||||
| OtherMiddleName: | F | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3375 US ROUTE 60 E | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 257052837 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045257851 | ||||||||
| FaxNumber: | 3046971286 | ||||||||
| Practice Location | |||||||||
| Address1: | 3375 US ROUTE 60 E | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 257052837 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045257851 | ||||||||
| FaxNumber: | 3046971286 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/07/2010 | ||||||||
| LastUpdateDate: | 01/07/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 853 | WV | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 0005355002 | 05 | WV | MEDICAID |