Provider Demographics
NPI:1689129694
Name:SMITH, ALICE (LMHC, CASAC)
Entity Type:Individual
Prefix:MRS
First Name:ALICE
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:LMHC, CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 PIKE ST
Mailing Address - Street 2:
Mailing Address - City:PORT JERVIS
Mailing Address - State:NY
Mailing Address - Zip Code:12771-1824
Mailing Address - Country:US
Mailing Address - Phone:845-856-7576
Mailing Address - Fax:845-856-8231
Practice Address - Street 1:123 PIKE ST
Practice Address - Street 2:
Practice Address - City:PORT JERVIS
Practice Address - State:NY
Practice Address - Zip Code:12771-1824
Practice Address - Country:US
Practice Address - Phone:845-856-7576
Practice Address - Fax:845-856-8231
Is Sole Proprietor?:No
Enumeration Date:2016-08-19
Last Update Date:2016-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000429101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY12588OtherNYS OASAS
NY000429OtherNEW YORK STATE OFFICE OF PROFESSIONS