Healthcare Provider Details

I. General information

NPI: 1497800775
Provider Name (Legal Business Name): CHRISTOPHER SMITH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/24/2007
Last Update Date: 08/12/2024
Certification Date: 08/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

54 TUSCARORA DR
CENTERPORT NY
11721-1553
US

IV. Provider business mailing address

54 TUSCARORA DR
CENTERPORT NY
11721-1553
US

V. Phone/Fax

Practice location:
  • Phone: 516-448-5172
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number014204
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number014204
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: