Healthcare Provider Details

I. General information

NPI: 1871878751
Provider Name (Legal Business Name): AMY H SMITH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2011
Last Update Date: 10/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1519 NYE RAOD
LYONS NY
14489
US

IV. Provider business mailing address

1519 NYE RAOD
LYONS NY
14489
US

V. Phone/Fax

Practice location:
  • Phone: 315-946-5722
  • Fax: 315-946-7079
Mailing address:
  • Phone: 315-946-5722
  • Fax: 315-946-7079

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberP81425
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: