Provider Demographics
NPI:1104146794
Name:SMITH, NOELLE (CASAC, MA)
Entity type:Individual
Prefix:
First Name:NOELLE
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:CASAC, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6207 WOODSIDE AVE
Mailing Address - Street 2:4TH FLOOR
Mailing Address - City:WOODSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11377-3653
Mailing Address - Country:US
Mailing Address - Phone:718-898-5085
Mailing Address - Fax:718-898-5582
Practice Address - Street 1:6207 WOODSIDE AVE
Practice Address - Street 2:4TH FLOOR
Practice Address - City:WOODSIDE
Practice Address - State:NY
Practice Address - Zip Code:11377-3653
Practice Address - Country:US
Practice Address - Phone:718-898-5085
Practice Address - Fax:718-898-5582
Is Sole Proprietor?:No
Enumeration Date:2010-06-04
Last Update Date:2010-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY24342101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)