Healthcare Provider Details

I. General information

NPI: 1649627480
Provider Name (Legal Business Name): JESSICA BUTTACAVOLI-SMITH PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2016
Last Update Date: 05/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7 SAINT PAUL ST
BALTIMORE MD
21202-1626
US

IV. Provider business mailing address

55 HATCHETTS HILL RD
OLD LYME CT
06371-1534
US

V. Phone/Fax

Practice location:
  • Phone: 800-370-3651
  • Fax:
Mailing address:
  • Phone: 800-370-3651
  • Fax: 877-515-7147

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number18
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: