1497819288 NPI number — MRS. DIANE ELLEN SMITH LMFT

Table of content: MRS. DANIELLE T AYER PT (NPI 1053695239)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497819288 NPI number — MRS. DIANE ELLEN SMITH LMFT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMITH
Provider First Name:
DIANE
Provider Middle Name:
ELLEN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LMFT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1497819288
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/03/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17 SCOTT DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OXFORD
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06478-1553
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-232-7667
Provider Business Mailing Address Fax Number:
203-881-9136

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
519 HERTIAGE ROAD
Provider Second Line Business Practice Location Address:
SUITE 2D
Provider Business Practice Location Address City Name:
SOUTHBURY
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06488-1699
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-232-7667
Provider Business Practice Location Address Fax Number:
203-881-9136
Provider Enumeration Date:
12/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  001054 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 106H00000X , with the licence number: 001054 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 008003522 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".




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