Provider Demographics
NPI:1285833772
Name:SMITH, JOHN ROBERT (CASAC)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:ROBERT
Last Name:SMITH
Suffix:
Gender:M
Credentials:CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 GOODRICH ST
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14203-1005
Mailing Address - Country:US
Mailing Address - Phone:716-859-2953
Mailing Address - Fax:716-859-2560
Practice Address - Street 1:80 GOODRICH ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14203-1005
Practice Address - Country:US
Practice Address - Phone:716-859-2953
Practice Address - Fax:716-859-2560
Is Sole Proprietor?:No
Enumeration Date:2007-07-13
Last Update Date:2007-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY11291101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health