1649753054 NPI number — SUSANAH B SMITH DEM, CLC

Table of content: SUSANAH B SMITH DEM, CLC (NPI 1649753054)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649753054 NPI number — SUSANAH B SMITH DEM, CLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMITH
Provider First Name:
SUSANAH
Provider Middle Name:
B
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DEM, CLC
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:
1649753054
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/20/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
25 S MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STEWARTSTOWN
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
17363-4084
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
443-388-4229
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
25 S MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STEWARTSTOWN
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17363-4084
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
443-388-4229
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/11/2018

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: 176B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 374J00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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