Provider Demographics
NPI:1275961237
Name:SMBM, LCSW, PLLC
Entity Type:Organization
Organization Name:SMBM, LCSW, PLLC
Other - Org Name:ADIRONDACK EQUINE ASSISTED PSYCHOTHERAPY, LCSW
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:
Authorized Official - Last Name:BROCK MYLES
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:518-573-0239
Mailing Address - Street 1:10 FOXHURST DR
Mailing Address - Street 2:
Mailing Address - City:QUEENSBURY
Mailing Address - State:NY
Mailing Address - Zip Code:12804-8488
Mailing Address - Country:US
Mailing Address - Phone:518-573-0239
Mailing Address - Fax:
Practice Address - Street 1:46 REYNOLDS RD
Practice Address - Street 2:
Practice Address - City:FORT EDWARD
Practice Address - State:NY
Practice Address - Zip Code:12828-9244
Practice Address - Country:US
Practice Address - Phone:518-573-0239
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-29
Last Update Date:2013-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY078314251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health