Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 102L00000X | Psychologist | 011542 | NY |
Y | 103T00000X | Psychologist | 011542 | NY |
NPI | 1013928795 |
---|---|
Provider Name | Mr. Adam Smith |
First Address | Staten Island, NY 10301-3813 |
Second Address | Staten Island, NY 10314-7609 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 10/08/2006 |
Last Update Date | 08/07/2007 |