Provider Demographics
NPI:1215232640
Name:SMITH, MARY BEARDALL (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:BEARDALL
Last Name:SMITH
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:MARY
Other - Middle Name:B
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:2653 SW 87TH DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32608-9313
Mailing Address - Country:US
Mailing Address - Phone:352-331-0020
Mailing Address - Fax:352-331-0022
Practice Address - Street 1:2653 SW 87TH DR
Practice Address - Street 2:SUITE A
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32608-9313
Practice Address - Country:US
Practice Address - Phone:352-331-0020
Practice Address - Fax:352-331-0022
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-15
Last Update Date:2020-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY8210103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical