Provider Demographics
NPI:1013928795
Name:SMITH, ADAM (PHD)
Entity Type:Individual
Prefix:MR
First Name:ADAM
Middle Name:
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 1:134 DUNCAN RD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10301-3813
Mailing Address - Country:US
Mailing Address - Phone:718-983-8872
Mailing Address - Fax:718-983-0348
Practice Address - Street 1:181 BRADLEY AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-7609
Practice Address - Country:US
Practice Address - Phone:718-983-8872
Practice Address - Fax:718-983-0348
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011542103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYV31352Medicare ID - Type Unspecified