Provider Demographics
NPI:1275635088
Name:SMITH, CHERYL LYNNE (MS)
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:LYNNE
Last Name:SMITH
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2809 SAINT MARYS RD
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:PA
Mailing Address - Zip Code:19003-2006
Mailing Address - Country:US
Mailing Address - Phone:484-368-9897
Mailing Address - Fax:
Practice Address - Street 1:2809 SAINT MARYS RD
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:PA
Practice Address - Zip Code:19003-2006
Practice Address - Country:US
Practice Address - Phone:484-368-9897
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2015-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC000728101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA2320957000OtherIBC
PA172986000OtherKEYSTONE
PA7443306OtherAETNA