Provider Demographics
NPI:1124385612
Name:SMITH, TAMMY S
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:S
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:875 MASSACHUSETTS AVE
Mailing Address - Street 2:25
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02139-3067
Mailing Address - Country:US
Mailing Address - Phone:781-832-0113
Mailing Address - Fax:
Practice Address - Street 1:875 MASSACHUSETTS AVE
Practice Address - Street 2:25
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02139-3067
Practice Address - Country:US
Practice Address - Phone:781-832-0113
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-20
Last Update Date:2014-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7359101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health