Provider Demographics
NPI:1104175744
Name:SMITH, EDMOND D (MSW)
Entity type:Individual
Prefix:
First Name:EDMOND
Middle Name:D
Last Name:SMITH
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 PERRY ST.
Mailing Address - Street 2:#135
Mailing Address - City:PUTNAM
Mailing Address - State:CT
Mailing Address - Zip Code:06260
Mailing Address - Country:US
Mailing Address - Phone:508-320-4157
Mailing Address - Fax:
Practice Address - Street 1:81 PLANTATION ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01604
Practice Address - Country:US
Practice Address - Phone:508-849-5600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-29
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA20261271041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical