Provider Demographics
NPI:1134451404
Name:SMITH, ROBERTA ANN (PHD, HSPP, RN)
Entity type:Individual
Prefix:DR
First Name:ROBERTA
Middle Name:ANN
Last Name:SMITH
Suffix:
Gender:F
Credentials:PHD, HSPP, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3029 RIVER BAY DR N
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46240-2985
Mailing Address - Country:US
Mailing Address - Phone:317-408-7816
Mailing Address - Fax:317-598-9924
Practice Address - Street 1:951 E 86TH ST
Practice Address - Street 2:EXECUTIVE NORTH, SUITE 140
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46240-1849
Practice Address - Country:US
Practice Address - Phone:317-408-7816
Practice Address - Fax:317-598-9924
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-11
Last Update Date:2010-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20042362A103T00000X
IN28115908A163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health