Healthcare Provider Details

I. General information

NPI: 1073210316
Provider Name (Legal Business Name): PETER SMITH PSYD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2023
Last Update Date: 03/23/2023
Certification Date: 03/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 LIVINGSTON LOOP STE 1
SANTA TERESA NM
88008-9753
US

IV. Provider business mailing address

60 BEACH ST
SOUTH PORTLAND ME
04106-1607
US

V. Phone/Fax

Practice location:
  • Phone: 505-506-2546
  • Fax: 575-201-7070
Mailing address:
  • Phone: 520-271-9673
  • Fax: 575-201-7070

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License Number
License Number State

VIII. Authorized Official

Name: CLAUDIA NARANJO
Title or Position: AUTHORIZED AGENT
Credential:
Phone: 915-256-9028