Provider Demographics
NPI:1093885592
Name:SMART, SUSAN (PHD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:
Last Name:SMART
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:SUSAN
Other - Middle Name:
Other - Last Name:SMART
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:22409 ELLIS DAVIS RD
Mailing Address - Street 2:
Mailing Address - City:PRAIRIE HOME
Mailing Address - State:MO
Mailing Address - Zip Code:65068-2143
Mailing Address - Country:US
Mailing Address - Phone:660-841-5031
Mailing Address - Fax:
Practice Address - Street 1:22409 ELLIS DAVIS RD
Practice Address - Street 2:
Practice Address - City:PRAIRIE HOME
Practice Address - State:MO
Practice Address - Zip Code:65068-2143
Practice Address - Country:US
Practice Address - Phone:660-841-5031
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2016-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000163196103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO499774826Medicaid
MO00071292Medicare ID - Type Unspecified