Healthcare Provider Details

I. General information

NPI: 1720002744
Provider Name (Legal Business Name): SAMUEL C SMITH PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

509 MCMILLEN ST
FORT ATKINSON WI
53538-1263
US

IV. Provider business mailing address

509 MCMILLEN ST
FORT ATKINSON WI
53538-1263
US

V. Phone/Fax

Practice location:
  • Phone: 920-563-7995
  • Fax: 920-568-6047
Mailing address:
  • Phone: 920-563-7995
  • Fax: 920-568-6047

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number528-056
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: