Provider Demographics
NPI:1700810884
Name:SMITH, PETER JOSEPH (PHD LCSW C)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:JOSEPH
Last Name:SMITH
Suffix:
Gender:M
Credentials:PHD LCSW C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5407 N CHARLES STREET
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21210-2024
Mailing Address - Country:US
Mailing Address - Phone:410-433-8861
Mailing Address - Fax:410-433-1249
Practice Address - Street 1:5407 N CHARLES STREET
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21210-2024
Practice Address - Country:US
Practice Address - Phone:410-433-8861
Practice Address - Fax:410-433-1249
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2011-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD06728104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
0009OtherFED BC
481448000OtherMAGELLAN
MD52282101OtherBCBS
MD52282101OtherBCBS