Basic Information
| Provider Information | |||||||||
| NPI: | 1841412673 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | EVAN | ||||||||
| MiddleName: | |||||||||
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| Credential: | CAT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1412 SWEET HOME RD STE 3-5 | ||||||||
| Address2: | |||||||||
| City: | AMHERST | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142282795 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7165891411 | ||||||||
| FaxNumber: | 7165591572 | ||||||||
| Practice Location | |||||||||
| Address1: | 1412 SWEET HOME RD | ||||||||
| Address2: | |||||||||
| City: | AMHERST | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142282795 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7165891411 | ||||||||
| FaxNumber: | 7168812425 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2007 | ||||||||
| LastUpdateDate: | 06/15/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 221700000X | 7901198 | NY | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Art Therapist | 104100000X | 001118-1 | NY | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.