MEDICARE: DR. SUSAN SMART PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	2000163196	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1093885592
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SUSAN SMART PH.D.

Provider Business Mailing Address
First Line	:	22409 ELLIS DAVIS RD
Second Line	:
City	:	PRAIRIE HOME
State	:	MO
Zip	:	65068-2143
Country	:	US
Telephone Number	:	660-841-5031
Fax Number	:

Provider Business Practice Location Address
First Line	:	22409 ELLIS DAVIS RD
Second Line	:
City	:	PRAIRIE HOME
State	:	MO
Zip	:	65068-2143
Country	:	US
Telephone Number	:	660-841-5031
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/09/2006
Last Update Date	:	08/01/2016

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