Provider Demographics
NPI:1205131265
Name:SMITH, JEFFREY D (LCSW-R)
Entity type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:D
Last Name:SMITH
Suffix:
Gender:M
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4
Mailing Address - Street 2:
Mailing Address - City:FERNDALE
Mailing Address - State:NY
Mailing Address - Zip Code:12734-0004
Mailing Address - Country:US
Mailing Address - Phone:845-794-3430
Mailing Address - Fax:845-794-4969
Practice Address - Street 1:23 SAINT JOHN ST
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:NY
Practice Address - Zip Code:12701-2149
Practice Address - Country:US
Practice Address - Phone:845-794-3430
Practice Address - Fax:845-794-4969
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-21
Last Update Date:2011-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR056850-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYR056850-1OtherNYS EDUCATION DEPR