=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235320003
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SMOCK & ASSOCIATES, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/07/2007
-----------------------------------------------------
Last Update Date | 08/07/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 134 N WATER ST
-----------------------------------------------------
City | LIBERTY
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64068-1737
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 816-781-6690
-----------------------------------------------------
Fax | 816-781-2897
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 134 N WATER ST
-----------------------------------------------------
City | LIBERTY
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64068-1737
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 816-781-6690
-----------------------------------------------------
Fax | 816-781-2897
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CORPORATE OFFICER/OFFICER MANAGER
-----------------------------------------------------
Name | MRS. HARRIET ALICE SMOCK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 816-781-6690
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PY00383
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------