Provider Demographics
NPI:1821130683
Name:SMITH, DEBORAH JEAN (PSYD)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:JEAN
Last Name:SMITH
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7901 LAKE WAUNATTA DR
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32792-8937
Mailing Address - Country:US
Mailing Address - Phone:407-619-1374
Mailing Address - Fax:
Practice Address - Street 1:711 BALLARD ST
Practice Address - Street 2:
Practice Address - City:ALTAMONTE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32701-5441
Practice Address - Country:US
Practice Address - Phone:407-331-1903
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY5675103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL54361Medicare ID - Type Unspecified