Provider Demographics
NPI:1497819288
Name:SMITH, DIANE ELLEN (LMFT)
Entity Type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:ELLEN
Last Name:SMITH
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 SCOTT DRIVE
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06478-1553
Mailing Address - Country:US
Mailing Address - Phone:203-232-7667
Mailing Address - Fax:203-881-9136
Practice Address - Street 1:519 HERTIAGE ROAD
Practice Address - Street 2:SUITE 2D
Practice Address - City:SOUTHBURY
Practice Address - State:CT
Practice Address - Zip Code:06488-1699
Practice Address - Country:US
Practice Address - Phone:203-232-7667
Practice Address - Fax:203-881-9136
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001054101YM0800X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008003522Medicaid