Provider Demographics
NPI:1326405291
Name:SMITH, STEPHEN MARK (PHD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:MARK
Last Name:SMITH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:608 MADISON ST
Mailing Address - Street 2:APT. #3
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11221-1606
Mailing Address - Country:US
Mailing Address - Phone:561-629-3434
Mailing Address - Fax:
Practice Address - Street 1:142 JORALEMON ST STE 5F
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-4709
Practice Address - Country:US
Practice Address - Phone:646-868-8396
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-24
Last Update Date:2018-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021515103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical