Provider Demographics
NPI:1417013442
Name:SMITH, CAROL LYNN (PHD)
Entity Type:Individual
Prefix:DR
First Name:CAROL
Middle Name:LYNN
Last Name:SMITH
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5600 MONROE STREET BLDG 'A' 201
Mailing Address - Street 2:
Mailing Address - City:SYLVANIA
Mailing Address - State:OH
Mailing Address - Zip Code:43560
Mailing Address - Country:US
Mailing Address - Phone:419-885-1910
Mailing Address - Fax:419-885-5060
Practice Address - Street 1:5600 MONROE STREET, BLDG 'A' #201
Practice Address - Street 2:SUITE E
Practice Address - City:SYLVANIA
Practice Address - State:OH
Practice Address - Zip Code:43560
Practice Address - Country:US
Practice Address - Phone:419-885-4121
Practice Address - Fax:419-885-6121
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-27
Last Update Date:2015-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5890103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHCP2881Medicare UPIN