Provider Demographics
NPI:1437184264
Name:SMITH, FREDERICK EARL (PHD)
Entity Type:Individual
Prefix:DR
First Name:FREDERICK
Middle Name:EARL
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 1:23 OVERBROOK DR
Mailing Address - Street 2:
Mailing Address - City:WELLESLEY
Mailing Address - State:MA
Mailing Address - Zip Code:02482-2216
Mailing Address - Country:US
Mailing Address - Phone:781-237-4735
Mailing Address - Fax:
Practice Address - Street 1:1132 WESTFIELD ST
Practice Address - Street 2:
Practice Address - City:WEST SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01089-3878
Practice Address - Country:US
Practice Address - Phone:413-439-0090
Practice Address - Fax:413-439-0096
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8074103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0503703Medicaid
MAW51138Medicare ID - Type Unspecified