Provider Demographics
NPI:1619271251
Name:SMYTH, CHARLENE A
Entity Type:Individual
Prefix:MS
First Name:CHARLENE
Middle Name:A
Last Name:SMYTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 BOULDER RD
Mailing Address - Street 2:
Mailing Address - City:SOLVAY
Mailing Address - State:NY
Mailing Address - Zip Code:13209-1713
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:301 VALLEY DR
Practice Address - Street 2:PARKSIDE CHILDREN'S CENTER
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13207-2298
Practice Address - Country:US
Practice Address - Phone:315-468-1632
Practice Address - Fax:315-468-1635
Is Sole Proprietor?:No
Enumeration Date:2010-12-22
Last Update Date:2010-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY307746031172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1598996571OtherPARKSIDE CHILDREN'S CENTER