Provider Demographics
NPI:1063679470
Name:SMITH, IRENE ALBERTA (CAC A&D)
Entity Type:Individual
Prefix:MS
First Name:IRENE
Middle Name:ALBERTA
Last Name:SMITH
Suffix:
Gender:F
Credentials:CAC A&D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BOONSBORO
Mailing Address - State:MD
Mailing Address - Zip Code:21713-1011
Mailing Address - Country:US
Mailing Address - Phone:301-432-8441
Mailing Address - Fax:
Practice Address - Street 1:1302 PENNSYLVANIA AVE
Practice Address - Street 2:CAMEO HOUSE
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21740
Practice Address - Country:US
Practice Address - Phone:240-313-3329
Practice Address - Fax:301-790-1314
Is Sole Proprietor?:No
Enumeration Date:2008-05-22
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDAC0257171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator