Healthcare Provider Details

I. General information

NPI: 1275193690
Provider Name (Legal Business Name): SMITH PSYCHOLOGY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2019
Last Update Date: 07/23/2020
Certification Date: 07/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 PLANDOME RD LOWR LEVEL
MANHASSET NY
11030-2303
US

IV. Provider business mailing address

75 PLANDOME RD LOWR LEVEL
MANHASSET NY
11030-2303
US

V. Phone/Fax

Practice location:
  • Phone: 516-384-6642
  • Fax:
Mailing address:
  • Phone: 516-384-6642
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1568738680
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer

VIII. Authorized Official

Name: DR. LINDA SMITH
Title or Position: PRESIDENT
Credential: PH.D.
Phone: 516-729-6557