Provider Demographics
NPI:1043500929
Name:SMITH, SANDRA J (LADC, CCS, LMSW-CC)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:J
Last Name:SMITH
Suffix:
Gender:F
Credentials:LADC, CCS, LMSW-CC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66 BARIBEAU DR
Mailing Address - Street 2:SUITE 1A
Mailing Address - City:BRUNSWICK
Mailing Address - State:ME
Mailing Address - Zip Code:04011-3230
Mailing Address - Country:US
Mailing Address - Phone:207-373-6996
Mailing Address - Fax:207-373-6959
Practice Address - Street 1:66 BARIBEAU DR
Practice Address - Street 2:SUITE 1A
Practice Address - City:BRUNSWICK
Practice Address - State:ME
Practice Address - Zip Code:04011-3230
Practice Address - Country:US
Practice Address - Phone:207-373-6996
Practice Address - Fax:207-373-6959
Is Sole Proprietor?:No
Enumeration Date:2011-04-13
Last Update Date:2024-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECAC4728101YA0400X
MELC5088101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME102140100Medicaid