MEDICARE: DR. SANDRA L. SMITH PH.D.

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	103TS0200X	School Psychologist	005469-1	NY

General Provider Information

NPI Number	:	1447266531
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SANDRA L. SMITH PH.D.

Provider Business Mailing Address
First Line	:	7000 E GENESEE ST
Second Line	:	BLDG.C
City	:	FAYETTEVILLE
State	:	NY
Zip	:	13066-1131
Country	:	US
Telephone Number	:	315-449-0851
Fax Number	:	315-449-0851

Provider Business Practice Location Address
First Line	:	7000 E GENESEE ST
Second Line	:	BLDG.C
City	:	FAYETTEVILLE
State	:	NY
Zip	:	13066-1131
Country	:	US
Telephone Number	:	315-449-0851
Fax Number	:	315-449-0851

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

Provider Enumeration Date	:	07/31/2006
Last Update Date	:	07/08/2007

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