Provider Demographics
NPI:1316008485
Name:SMITH, PETER JOSERPH (LCSW)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:JOSERPH
Last Name:SMITH
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 WHITEWOOD DRIVE
Mailing Address - Street 2:
Mailing Address - City:ROCKY POINT
Mailing Address - State:NY
Mailing Address - Zip Code:11778-9323
Mailing Address - Country:US
Mailing Address - Phone:631-821-1362
Mailing Address - Fax:631-665-0442
Practice Address - Street 1:131 RT 25A
Practice Address - Street 2:
Practice Address - City:ROCKY POINT
Practice Address - State:NY
Practice Address - Zip Code:11778-9098
Practice Address - Country:US
Practice Address - Phone:631-665-0229
Practice Address - Fax:631-665-0442
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2017-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY027153LCSWR1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02432213Medicaid
NYN160G1Medicare ID - Type Unspecified
R46561Medicare UPIN