Provider Demographics
NPI:1699833517
Name:SMICKLEY, SCOTT M (PSYD)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:M
Last Name:SMICKLEY
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:79 S COURTLAND ST
Mailing Address - Street 2:
Mailing Address - City:EAST STROUDSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:18301-2865
Mailing Address - Country:US
Mailing Address - Phone:570-476-6301
Mailing Address - Fax:570-421-7077
Practice Address - Street 1:79 S COURTLAND ST
Practice Address - Street 2:
Practice Address - City:EAST STROUDSBURG
Practice Address - State:PA
Practice Address - Zip Code:18301-2865
Practice Address - Country:US
Practice Address - Phone:570-476-6301
Practice Address - Fax:570-421-7077
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS-005696-L103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA633070Medicare ID - Type UnspecifiedPSYCHOLOGIST