MEDICARE: EVELYN M SMITH MA LCMHC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	0680000219	VT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1336123918
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EVELYN M SMITH MA LCMHC

Provider Business Mailing Address
First Line	:	PO BOX 136
Second Line	:
City	:	SHELBURNE
State	:	VT
Zip	:	05482-0136
Country	:	US
Telephone Number	:	802-578-0342
Fax Number	:

Provider Business Practice Location Address
First Line	:	145 PINE HAVEN SHORES RD STE 2103
Second Line	:
City	:	SHELBURNE
State	:	VT
Zip	:	05482-7703
Country	:	US
Telephone Number	:	802-578-0342
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/06/2005
Last Update Date	:	06/07/2024

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