Healthcare Provider Details

I. General information

NPI: 1568852952
Provider Name (Legal Business Name): MARY CLARE SMITH PHD, ATR-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY/CAROL ROBERT CLARE/ROBERTA SMITH

II. Dates (important events)

Enumeration Date: 01/23/2015
Last Update Date: 05/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 22ND ST
TOLEDO OH
43604-2706
US

IV. Provider business mailing address

123 22ND ST
TOLEDO OH
43604-2706
US

V. Phone/Fax

Practice location:
  • Phone: 419-241-6191
  • Fax:
Mailing address:
  • Phone: 419-241-6191
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0810005000
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number7217
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code221700000X
TaxonomyArt Therapist
License Number98-119
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: