Provider Demographics
NPI:1659502490
Name:SMITH, ETHAN BENNET (MSW)
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:BENNET
Last Name:SMITH
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:94 LIVINGSTON ST
Mailing Address - Street 2:APT. 25
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511-2444
Mailing Address - Country:US
Mailing Address - Phone:301-466-4646
Mailing Address - Fax:
Practice Address - Street 1:95 CIRCULAR AVE
Practice Address - Street 2:
Practice Address - City:HAMDEN
Practice Address - State:CT
Practice Address - Zip Code:06514-4004
Practice Address - Country:US
Practice Address - Phone:203-288-6253
Practice Address - Fax:203-288-0948
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-28
Last Update Date:2009-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health