Basic Information
Provider Information | |||||||||
NPI: | 1609947738 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SMITH | ||||||||
FirstName: | ROBERT | ||||||||
MiddleName: | J. | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | LCSW,LADC,LMFT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 19 APPLEWOOD DR | ||||||||
Address2: |   | ||||||||
City: | MERIDEN | ||||||||
State: | CT | ||||||||
PostalCode: | 064507901 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2032383498 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 435 E MAIN ST | ||||||||
Address2: |   | ||||||||
City: | ANSONIA | ||||||||
State: | CT | ||||||||
PostalCode: | 064011964 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2037362905 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/12/2006 | ||||||||
LastUpdateDate: | 07/29/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 000303 | CT | N |   | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 1041C0700X | 000405 | CT | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical | 106H00000X | 000323 | CT | N |   | Behavioral Health & Social Service Providers | Marriage & Family Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 4183480 | 05 | CT |   | MEDICAID |