Provider Demographics
NPI:1417535956
Name:SMITH, JAMES GORDON III
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:GORDON
Last Name:SMITH
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1350 LIMIT AVE
Mailing Address - Street 2:
Mailing Address - City:IDLEWYLDE
Mailing Address - State:MD
Mailing Address - Zip Code:21239-1724
Mailing Address - Country:US
Mailing Address - Phone:410-350-5452
Mailing Address - Fax:
Practice Address - Street 1:5820 YORK RD STE 201
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21212-3620
Practice Address - Country:US
Practice Address - Phone:410-800-2169
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-29
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP11308101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health