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General NPI Number Information
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NPI Number | 1376720441
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Entity Type | Individual
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Provider Name | RONALD GLENN SMITH PH.D.
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Gender | Male
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Dates
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Enumeration Date | 01/30/2008
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Last Update Date | 01/30/2008
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Provider Practice Location Address
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Address Line | 55 LAKE HAVASU AVE S STE. F-365
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City | LAKE HAVASU CITY
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State | AZ
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Zip | 86403-0938
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Country | US
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Telephone | 928-854-2373
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Fax | 928-680-9811
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Provider Business Mailing Address
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Address Line | 2035 MESQUITE AVE STE. C
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City | LAKE HAVASU CITY
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State | AZ
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Zip | 86403-5894
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Country | US
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Telephone | 928-854-2373
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Fax | 928-680-9811
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 0954
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License Number State | AZ
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