Healthcare Provider Details

I. General information

NPI: 1447266531
Provider Name (Legal Business Name): SANDRA L. SMITH PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7000 E GENESEE ST BLDG.C
FAYETTEVILLE NY
13066-1131
US

IV. Provider business mailing address

7000 E GENESEE ST BLDG.C
FAYETTEVILLE NY
13066-1131
US

V. Phone/Fax

Practice location:
  • Phone: 315-449-0851
  • Fax: 315-449-0851
Mailing address:
  • Phone: 315-449-0851
  • Fax: 315-449-0851

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number005469-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: