Provider Demographics
NPI:1508061169
Name:SMITH, PETER NORMAN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:NORMAN
Last Name:SMITH
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 BEACH ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-1607
Mailing Address - Country:US
Mailing Address - Phone:505-506-2546
Mailing Address - Fax:575-201-7070
Practice Address - Street 1:101 LIVINGSTON LOOP STE 1
Practice Address - Street 2:
Practice Address - City:SANTA TERESA
Practice Address - State:NM
Practice Address - Zip Code:88008-9753
Practice Address - Country:US
Practice Address - Phone:505-506-2546
Practice Address - Fax:575-201-7070
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-15
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1290103TC0700X
NM0039C103TP0016X
NMPSY-RXP0053103TP0016X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TP0016XBehavioral Health & Social Service ProvidersPsychologistPrescribing (Medical)
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ4320OtherBCIA-C
AZ612352100OtherDOL FECA
NM22639560Medicaid
AZE-1463OtherBCIAC-EEG
NM1290OtherNM PSYCHOLOGIST
NMPSY-RXP0053OtherSTATE OF NEW MEXICO BOARD OF PSYCHOLOGIST EXAMINERS
NMPSY-RXP0053OtherSTATE OF NEW MEXICO BOARD OF PSYCHOLOGIST EXAMINERS
NM1290OtherNM PSYCHOLOGIST