Provider Demographics
NPI:1659372753
Name:SMITH, ALAN JAY (PHD)
Entity Type:Individual
Prefix:DR
First Name:ALAN
Middle Name:JAY
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 1:2618 AVENUE C
Mailing Address - Street 2:
Mailing Address - City:SCOTTSBLUFF
Mailing Address - State:NE
Mailing Address - Zip Code:69361-1680
Mailing Address - Country:US
Mailing Address - Phone:308-632-8547
Mailing Address - Fax:308-632-0135
Practice Address - Street 1:2618 AVENUE C
Practice Address - Street 2:
Practice Address - City:SCOTTSBLUFF
Practice Address - State:NE
Practice Address - Zip Code:69361-1680
Practice Address - Country:US
Practice Address - Phone:308-632-8547
Practice Address - Fax:308-632-0135
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-10
Last Update Date:2012-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE296103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE08317OtherBLUE CROSS BLUE SHIELD
NE10025416200Medicaid
260663Medicare ID - Type Unspecified