Provider Demographics
NPI:1790801744
Name:SMITH, CLIFFORD O (PHD)
Entity Type:Individual
Prefix:DR
First Name:CLIFFORD
Middle Name:O
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 1:3608 LANCASTER PIKE
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19805-1509
Mailing Address - Country:US
Mailing Address - Phone:302-995-9600
Mailing Address - Fax:302-995-9571
Practice Address - Street 1:3608 LANCASTER PIKE
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19805-1509
Practice Address - Country:US
Practice Address - Phone:302-995-9600
Practice Address - Fax:302-995-9571
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAB10000101103TC0700X, 103T00000X, 103TP2701X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE490973Medicare ID - Type UnspecifiedPROVIDER NUMBER