Provider Demographics
NPI:1811941776
Name:SMITH, HEATHER LEE (PSYD)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:LEE
Last Name:SMITH
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 1:1711 W WHEELER AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:ARANSAS PASS
Mailing Address - State:TX
Mailing Address - Zip Code:78336-4536
Mailing Address - Country:US
Mailing Address - Phone:361-887-9600
Mailing Address - Fax:361-883-1661
Practice Address - Street 1:1711 W WHEELER AVE STE 2
Practice Address - Street 2:
Practice Address - City:ARANSAS PASS
Practice Address - State:TX
Practice Address - Zip Code:78336-4536
Practice Address - Country:US
Practice Address - Phone:361-887-9600
Practice Address - Fax:361-883-1661
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2013-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX33053103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX180683802Medicaid
TX8J0969Medicare PIN