Provider Demographics
NPI:1790346807
Name:SMITH, JANET THERESA
Entity Type:Individual
Prefix:
First Name:JANET
Middle Name:THERESA
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 W MOSHOLU PKWY S APT 34M
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10468-1155
Mailing Address - Country:US
Mailing Address - Phone:929-227-0069
Mailing Address - Fax:
Practice Address - Street 1:20 W MOSHOLU PKWY S APT 34M
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10468-1155
Practice Address - Country:US
Practice Address - Phone:929-227-0069
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-28
Last Update Date:2019-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 251B00000X
NY04037-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No251B00000XAgenciesCase ManagementGroup - Single Specialty