Healthcare Provider Details

I. General information

NPI: 1235455874
Provider Name (Legal Business Name): BERNARD A SMITH LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2010
Last Update Date: 09/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 COMMERCE LN
CANTON NY
13617-3739
US

IV. Provider business mailing address

4 COMMERCE LN
CANTON NY
13617-3739
US

V. Phone/Fax

Practice location:
  • Phone: 315-386-8191
  • Fax: 315-386-1410
Mailing address:
  • Phone: 315-386-8191
  • Fax: 315-386-1410

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberR057519-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberR057519
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: