Provider Demographics
NPI:1063912921
Name:SMITH, DEONDRA (PSYD)
Entity type:Individual
Prefix:DR
First Name:DEONDRA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:DEONDRA
Other - Middle Name:
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:PO BOX 1575
Mailing Address - Street 2:
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21060-1575
Mailing Address - Country:US
Mailing Address - Phone:240-776-5551
Mailing Address - Fax:
Practice Address - Street 1:325 GAMBRILLS RD STE F
Practice Address - Street 2:
Practice Address - City:GAMBRILLS
Practice Address - State:MD
Practice Address - Zip Code:21054-1102
Practice Address - Country:US
Practice Address - Phone:443-917-3534
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-17
Last Update Date:2018-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD05785103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical