Provider Demographics
NPI:1235120536
Name:SMITH, SCOTT EDWARD (PHD)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:EDWARD
Last Name:SMITH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1509 RITCHIE HIGHWAY
Mailing Address - Street 2:STE F
Mailing Address - City:ARNOLD
Mailing Address - State:MD
Mailing Address - Zip Code:21012
Mailing Address - Country:US
Mailing Address - Phone:410-757-2077
Mailing Address - Fax:410-757-5184
Practice Address - Street 1:1509 RITCHIE HIGHWAY
Practice Address - Street 2:STE F
Practice Address - City:ARNOLD
Practice Address - State:MD
Practice Address - Zip Code:21012
Practice Address - Country:US
Practice Address - Phone:410-757-2077
Practice Address - Fax:410-757-5184
Is Sole Proprietor?:No
Enumeration Date:2005-11-04
Last Update Date:2010-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD02550103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD222L276BMedicare ID - Type Unspecified