Provider Demographics
NPI:1659364180
Name:SMITH, JAMES RALPH (PHD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:RALPH
Last Name:SMITH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2506 GALEN DR
Mailing Address - Street 2:SUITE 103
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61821-7046
Mailing Address - Country:US
Mailing Address - Phone:217-398-0744
Mailing Address - Fax:217-398-0778
Practice Address - Street 1:2506 GALEN DR
Practice Address - Street 2:SUITE 103
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61821-7046
Practice Address - Country:US
Practice Address - Phone:217-398-0744
Practice Address - Fax:217-398-0778
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-30
Last Update Date:2012-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071-003744103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL210023Medicare ID - Type Unspecified