Healthcare Provider Details

I. General information

NPI: 1790779775
Provider Name (Legal Business Name): MARK RANDALL SMITH PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2005
Last Update Date: 10/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

904 HWY 15 SOUTH FRONTAGE RD. SUITE H
HUTCHINSON MN
55350
US

IV. Provider business mailing address

904 HWY 15 SOUTH FRONTAGE RD. SUITE H
HUTCHINSON MN
55350
US

V. Phone/Fax

Practice location:
  • Phone: 320-587-2939
  • Fax: 320-864-1927
Mailing address:
  • Phone: 320-587-2939
  • Fax: 320-864-1927

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberLP2907
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: