Provider Demographics
NPI:1447467378
Name:SMITH, SAMUEL LEE (RD)
Entity type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:LEE
Last Name:SMITH
Suffix:
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:SHELTON
Mailing Address - State:CT
Mailing Address - Zip Code:06484-2131
Mailing Address - Country:US
Mailing Address - Phone:203-402-0341
Mailing Address - Fax:203-402-0341
Practice Address - Street 1:80 PHOENIX AVE
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06702-1418
Practice Address - Country:US
Practice Address - Phone:203-756-8021
Practice Address - Fax:203-596-9038
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000491133NN1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education