Provider Demographics
NPI:1639537798
Name:SMITH, ALICIA L (PSYD)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:L
Last Name:SMITH
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:ALICIA
Other - Middle Name:LYNN
Other - Last Name:FOSTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10 HALE ST STE 206
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25301-2830
Mailing Address - Country:US
Mailing Address - Phone:304-205-4129
Mailing Address - Fax:304-205-4130
Practice Address - Street 1:10 HALE ST STE 206
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-2830
Practice Address - Country:US
Practice Address - Phone:304-205-4129
Practice Address - Fax:304-205-4130
Is Sole Proprietor?:No
Enumeration Date:2016-02-04
Last Update Date:2020-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1133103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV9262581OtherGROUP MEDICARE
WV9262581OtherGROUP MEDICARE
WVQ52808BMedicare PIN
WV9262581OtherGROUP MEDICARE
OH0157169Medicaid