Basic Information
| Provider Information | |||||||||
| NPI: | 1568852952 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | CLARE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHD, ATR-BC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SMITH | ||||||||
| OtherFirstName: | MARY/CAROL | ||||||||
| OtherMiddleName: | ROBERT CLARE/ROBERTA | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 123 22ND ST | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436042706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192416191 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 123 22ND ST | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436042706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192416191 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2015 | ||||||||
| LastUpdateDate: | 05/30/2015 | ||||||||
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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 | 0810005000 | VA | N | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC1900X | 7217 | OH | Y | Behavioral Health & Social Service Providers | Psychologist | Counseling | 221700000X | 98-119 | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Art Therapist |
No ID Information.