Provider Demographics
NPI:1649233909
Name:SMITH, JANIS DIANE (PHD)
Entity Type:Individual
Prefix:DR
First Name:JANIS
Middle Name:DIANE
Last Name:SMITH
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:JANIS
Other - Middle Name:DIANE
Other - Last Name:EDISON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:1401 W CENTRAL PARK AVE
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52804-1707
Mailing Address - Country:US
Mailing Address - Phone:563-421-2390
Mailing Address - Fax:563-421-1430
Practice Address - Street 1:1401 W CENTRAL PARK AVE
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52804-1707
Practice Address - Country:US
Practice Address - Phone:563-421-2390
Practice Address - Fax:563-421-1430
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00895103TC0700X
PAPS-006763-L103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical