Provider Demographics
NPI:1508924549
Name:SMITH, LAUREL A (PSYD)
Entity Type:Individual
Prefix:DR
First Name:LAUREL
Middle Name:A
Last Name:SMITH
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2098 PORTAGE RD
Mailing Address - Street 2:SUITE 175
Mailing Address - City:WOOSTER
Mailing Address - State:OH
Mailing Address - Zip Code:44691-1970
Mailing Address - Country:US
Mailing Address - Phone:330-264-1999
Mailing Address - Fax:330-264-1999
Practice Address - Street 1:2098 PORTAGE RD
Practice Address - Street 2:SUITE 175
Practice Address - City:WOOSTER
Practice Address - State:OH
Practice Address - Zip Code:44691-1970
Practice Address - Country:US
Practice Address - Phone:330-264-1999
Practice Address - Fax:330-264-1999
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5005103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0167091Medicaid
OHCP17552Medicare ID - Type Unspecified
OH0167091Medicaid