Provider Demographics
NPI:1811391089
Name:SMITH, HEATHER CHRISTINE (MS)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:CHRISTINE
Last Name:SMITH
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1706 ADDISON ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19146-1517
Mailing Address - Country:US
Mailing Address - Phone:215-932-0727
Mailing Address - Fax:
Practice Address - Street 1:1706 ADDISON ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19146-1517
Practice Address - Country:US
Practice Address - Phone:215-932-0727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-17
Last Update Date:2014-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA232828922101YM0800X
PA101YM0800X101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAYWP80145325400OtherCAPITAL BLUE