Provider Demographics
NPI:1740631563
Name:SMYTH, ELIZABETH JESSICA (PSYD)
Entity type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:JESSICA
Last Name:SMYTH
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 SMITHTOWN BYP STE 224
Mailing Address - Street 2:
Mailing Address - City:HAUPPAUGE
Mailing Address - State:NY
Mailing Address - Zip Code:11788-2512
Mailing Address - Country:US
Mailing Address - Phone:631-528-5880
Mailing Address - Fax:631-528-5382
Practice Address - Street 1:111 SMITHTOWN BYP STE 224
Practice Address - Street 2:
Practice Address - City:HAUPPAUGE
Practice Address - State:NY
Practice Address - Zip Code:11788-2512
Practice Address - Country:US
Practice Address - Phone:631-528-5880
Practice Address - Fax:631-528-5382
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-22
Last Update Date:2020-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX37202103TC0700X
NY021682103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1740631563OtherOUT-OF-NETWORK PROVIDER