Provider Demographics
NPI:1669569703
Name:SMITH, ALAN MARC (SCD)
Entity type:Individual
Prefix:DR
First Name:ALAN
Middle Name:MARC
Last Name:SMITH
Suffix:
Gender:M
Credentials:SCD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 OLD STAGECOACH RD
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:01730-1296
Mailing Address - Country:US
Mailing Address - Phone:781-275-1095
Mailing Address - Fax:781-273-3399
Practice Address - Street 1:101 CAMBRIDGE ST 300
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:MA
Practice Address - Zip Code:01803-3768
Practice Address - Country:US
Practice Address - Phone:781-273-3399
Practice Address - Fax:781-273-3399
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-09
Last Update Date:2015-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2081103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0506028Medicaid
MASM W50716Medicare ID - Type Unspecified