Provider Demographics
NPI:1447266531
Name:SMITH, SANDRA L (PHD)
Entity type:Individual
Prefix:DR
First Name:SANDRA
Middle Name:L
Last Name:SMITH
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7000 E GENESEE ST
Mailing Address - Street 2:BLDG.C
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13066-1131
Mailing Address - Country:US
Mailing Address - Phone:315-449-0851
Mailing Address - Fax:315-449-0851
Practice Address - Street 1:7000 E GENESEE ST
Practice Address - Street 2:BLDG.C
Practice Address - City:FAYETTEVILLE
Practice Address - State:NY
Practice Address - Zip Code:13066-1131
Practice Address - Country:US
Practice Address - Phone:315-449-0851
Practice Address - Fax:315-449-0851
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005469-1103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool