Provider Demographics
NPI:1497952030
Name:SMITH, NICHOLAS W (MA)
Entity Type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:W
Last Name:SMITH
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1363 HIGHWAY A1A
Mailing Address - Street 2:
Mailing Address - City:SATELLITE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32937-2407
Mailing Address - Country:US
Mailing Address - Phone:321-779-8119
Mailing Address - Fax:321-773-0810
Practice Address - Street 1:1363 HIGHWAY A1A
Practice Address - Street 2:
Practice Address - City:SATELLITE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32937-2407
Practice Address - Country:US
Practice Address - Phone:321-777-0119
Practice Address - Fax:321-773-0810
Is Sole Proprietor?:No
Enumeration Date:2007-06-28
Last Update Date:2012-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH 3570101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health