Provider Demographics
NPI:1568659472
Name:SMITH, PHILIP JOHN (PHD)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:JOHN
Last Name:SMITH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 SCHOOL ST
Mailing Address - Street 2:
Mailing Address - City:WATERVILLE
Mailing Address - State:ME
Mailing Address - Zip Code:04901-7518
Mailing Address - Country:US
Mailing Address - Phone:207-873-5988
Mailing Address - Fax:
Practice Address - Street 1:2 SCHOOL ST
Practice Address - Street 2:
Practice Address - City:WATERVILLE
Practice Address - State:ME
Practice Address - Zip Code:04901-7518
Practice Address - Country:US
Practice Address - Phone:207-873-5988
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-25
Last Update Date:2007-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPS486103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MM3170Medicare PIN