Provider Demographics
NPI:1891949921
Name:SMITH, RYAN ELLIOTT (LGSW)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:ELLIOTT
Last Name:SMITH
Suffix:
Gender:M
Credentials:LGSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 WEBER ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21230-4106
Mailing Address - Country:US
Mailing Address - Phone:410-752-5525
Mailing Address - Fax:410-752-5531
Practice Address - Street 1:122 WEBER ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21230-4106
Practice Address - Country:US
Practice Address - Phone:410-752-5525
Practice Address - Fax:410-752-5531
Is Sole Proprietor?:No
Enumeration Date:2008-11-17
Last Update Date:2008-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDG12227104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD212150600Medicaid