MEDICARE: HEATHER CHRISTINE SMITH M.S

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	101YM0800X	Mental Health Counselor	232828922	PA
2	101YM0800X	Mental Health Counselor	101YM0800X	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	YWP80145325400	OTHER	PA	CAPITAL BLUE

General Provider Information

NPI Number	:	1811391089
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HEATHER CHRISTINE SMITH M.S

Provider Business Mailing Address
First Line	:	1706 ADDISON ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19146-1517
Country	:	US
Telephone Number	:	215-932-0727
Fax Number	:

Provider Business Practice Location Address
First Line	:	1706 ADDISON ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19146-1517
Country	:	US
Telephone Number	:	215-932-0727
Fax Number	:

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

Provider Enumeration Date	:	10/17/2014
Last Update Date	:	10/17/2014

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