=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003923392
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELLEN M SMITH LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/24/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 31 COLLEGEVIEW AVE
-----------------------------------------------------
City | POUGHKEEPSIE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12603-2406
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-485-2004
-----------------------------------------------------
Fax | 845-622-3851
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 86
-----------------------------------------------------
City | PLEASANT VALLEY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12569-0086
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-485-2004
-----------------------------------------------------
Fax | 845-622-3851
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | R033876
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------