Provider Demographics
NPI:1568063469
Name:SMITH, MATTHEW JAMES
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:JAMES
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24799 PURCELL RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH BLOOMINGVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43152-9740
Mailing Address - Country:US
Mailing Address - Phone:614-302-2866
Mailing Address - Fax:
Practice Address - Street 1:24799 PURCELL RD
Practice Address - Street 2:
Practice Address - City:SOUTH BLOOMINGVILLE
Practice Address - State:OH
Practice Address - Zip Code:43152-9740
Practice Address - Country:US
Practice Address - Phone:614-302-2866
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-06
Last Update Date:2020-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.17017711041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical