Provider Demographics
NPI:1750762332
Name:SMYTH, MARY (LAC)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:SMYTH
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:THOMPSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LAC
Mailing Address - Street 1:42 DELSEA DR S
Mailing Address - Street 2:
Mailing Address - City:GLASSBORO
Mailing Address - State:NJ
Mailing Address - Zip Code:08028-2621
Mailing Address - Country:US
Mailing Address - Phone:856-863-0006
Mailing Address - Fax:
Practice Address - Street 1:42 DELSEA DR S
Practice Address - Street 2:
Practice Address - City:GLASSBORO
Practice Address - State:NJ
Practice Address - Zip Code:08028-2621
Practice Address - Country:US
Practice Address - Phone:856-863-0006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-09
Last Update Date:2016-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00198300101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional