Basic Information
| Provider Information | |||||||||
| NPI: | 1194722181 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | ROY | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 N. 7TH STREET | ||||||||
| Address2: | |||||||||
| City: | LEBANON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170465040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7172731710 | ||||||||
| FaxNumber: | 7172731416 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 N. 7TH STREET | ||||||||
| Address2: | |||||||||
| City: | LEBANON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170465040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7172721653 | ||||||||
| FaxNumber: | 7172724166 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2005 | ||||||||
| LastUpdateDate: | 12/11/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | PS004266L | PA | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 001511178 | 05 | PA | MEDICAID |