Healthcare Provider Details

I. General information

NPI: 1669983219
Provider Name (Legal Business Name): AIYANA SMITH LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/21/2017
Last Update Date: 11/29/2024
Certification Date: 11/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 CHURCH ST
SOUTHAMPTON NY
11968-1196
US

IV. Provider business mailing address

26 HILL ST STE 114
SOUTHAMPTON NY
11968-5317
US

V. Phone/Fax

Practice location:
  • Phone: 631-343-5632
  • Fax:
Mailing address:
  • Phone: 631-209-7815
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number094249-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: