Provider Demographics
NPI:1649630633
Name:SMITH, CHARLES ELMORE
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:ELMORE
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 DALTON PL
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01109-1611
Mailing Address - Country:US
Mailing Address - Phone:413-885-0416
Mailing Address - Fax:
Practice Address - Street 1:28 DALTON PL
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01109-1611
Practice Address - Country:US
Practice Address - Phone:413-885-0416
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-03
Last Update Date:2016-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health