Healthcare Provider Details

I. General information

NPI: 1114150364
Provider Name (Legal Business Name): MARK CHRISTOPHER SMITH PSY.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2009
Last Update Date: 09/03/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 N HIATUS RD SUITE 213
PEMBROKE PINES FL
33026-5206
US

IV. Provider business mailing address

700 N HIATUS RD SUITE 213
PEMBROKE PINES FL
33026-5206
US

V. Phone/Fax

Practice location:
  • Phone: 954-431-0411
  • Fax: 954-431-0413
Mailing address:
  • Phone: 954-431-0411
  • Fax: 954-431-0413

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPY 7937
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: