MEDICARE: MAVIS LAUREN SMOOK

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	103K00000X	Behavior Analyst	103K00000X	NY

General Provider Information

NPI Number	:	1538523154
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MAVIS LAUREN SMOOK

Provider Business Mailing Address
First Line	:	6725 CLYDE ST
Second Line	:	2M
City	:	FOREST HILLS
State	:	NY
Zip	:	11375-4056
Country	:	US
Telephone Number	:	347-907-1210
Fax Number	:

Provider Business Practice Location Address
First Line	:	6725 CLYDE ST
Second Line	:	2M
City	:	FOREST HILLS
State	:	NY
Zip	:	11375-4056
Country	:	US
Telephone Number	:	718-263-5653
Fax Number	:

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

Provider Enumeration Date	:	04/09/2016
Last Update Date	:	04/09/2016

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Directions to “ MAVIS LAUREN SMOOK ” Practice Location

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