Provider Demographics
NPI:1932172012
Name:SMITH, MICHAEL D (LCSWR)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:D
Last Name:SMITH
Suffix:
Gender:M
Credentials:LCSWR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 MONTAUK HWY
Mailing Address - Street 2:STE-8
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706
Mailing Address - Country:US
Mailing Address - Phone:631-647-9009
Mailing Address - Fax:
Practice Address - Street 1:260 MONTAUK HWY
Practice Address - Street 2:STE-8
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706
Practice Address - Country:US
Practice Address - Phone:631-647-9009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2008-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0551041104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MHS273469OtherVALUE OPTIONS
NY02389706Medicaid
NYN2J081Medicare ID - Type Unspecified