Healthcare Provider Details

I. General information

NPI: 1306875612
Provider Name (Legal Business Name): PETER J. SMITH ED.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2006
Last Update Date: 01/17/2021
Certification Date: 01/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 WESTGREEN DR SUITE 201
CHAPEL HILL NC
27516-4417
US

IV. Provider business mailing address

100 WESTGREEN DR SUITE 201
CHAPEL HILL NC
27516-4417
US

V. Phone/Fax

Practice location:
  • Phone: 919-933-6500
  • Fax: 919-933-0334
Mailing address:
  • Phone: 919-933-6500
  • Fax: 919-933-0334

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License Number2105
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number2105
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number2105
License Number StateNC
# 4
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number2105
License Number StateNC
# 5
Primary TaxonomyN
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number2105
License Number StateNC
# 6
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number2105
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: