Provider Demographics
NPI:1205965480
Name:SMITH, C RIVER (PHD)
Entity type:Individual
Prefix:
First Name:C
Middle Name:RIVER
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 1:11206 CLIFTON BLVD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44102-1407
Mailing Address - Country:US
Mailing Address - Phone:216-651-1302
Mailing Address - Fax:
Practice Address - Street 1:11206 CLIFTON BLVD
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44102-1407
Practice Address - Country:US
Practice Address - Phone:216-651-1302
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4658103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0923479Medicaid
OHCP13151Medicare ID - Type UnspecifiedPSYCHOLOGIST