Healthcare Provider Details

I. General information

NPI: 1437184264
Provider Name (Legal Business Name): FREDERICK EARL SMITH PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1132 WESTFIELD ST
WEST SPRINGFIELD MA
01089-3878
US

IV. Provider business mailing address

23 OVERBROOK DR
WELLESLEY MA
02482-2216
US

V. Phone/Fax

Practice location:
  • Phone: 413-439-0090
  • Fax: 413-439-0096
Mailing address:
  • Phone: 781-237-4735
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number8074
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: