Provider Demographics
NPI:1235276205
Name:SMITH, EILEEN B (EDD)
Entity Type:Individual
Prefix:
First Name:EILEEN
Middle Name:B
Last Name:SMITH
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4825 E ROOSEVELT ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85008-5917
Mailing Address - Country:US
Mailing Address - Phone:602-629-6500
Mailing Address - Fax:602-629-6504
Practice Address - Street 1:4825 E ROOSEVELT ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85008-5917
Practice Address - Country:US
Practice Address - Phone:602-629-6500
Practice Address - Fax:602-629-6504
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ103TS0200X103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ581456Medicaid