MEDICARE: ADELAIDE S. SMITH LICSW

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	1041C0700X	Clinical Social Worker	ISW01640	RI
2	1041C0700X	Clinical Social Worker	103294	MA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P01256	OTHER	MA	BLUESHIELD AND BLUECROSS

General Provider Information

NPI Number	:	1114029006
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ADELAIDE S. SMITH LICSW

Provider Business Mailing Address
First Line	:	1 FITCHBURG ST APT C220
Second Line	:
City	:	SOMERVILLE
State	:	MA
Zip	:	02143-2127
Country	:	US
Telephone Number	:	617-764-0056
Fax Number	:	425-799-8790

Provider Business Practice Location Address
First Line	:	2464 MASSACHUSETTS AVE
Second Line	:	SUITE 220
City	:	CAMBRIDGE
State	:	MA
Zip	:	02140-1646
Country	:	US
Telephone Number	:	617-930-6902
Fax Number	:	425-799-8790

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

Provider Enumeration Date	:	09/02/2006
Last Update Date	:	07/08/2007

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