Provider Demographics
NPI:1194970301
Name:SMITH, SANDRA GALLIANI (LCPC)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:GALLIANI
Last Name:SMITH
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 EAST DIAMOND AVENUE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20877
Mailing Address - Country:US
Mailing Address - Phone:301-840-3200
Mailing Address - Fax:301-840-1348
Practice Address - Street 1:610 E DIAMOND AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20877-5321
Practice Address - Country:US
Practice Address - Phone:301-840-3200
Practice Address - Fax:301-840-1348
Is Sole Proprietor?:No
Enumeration Date:2008-12-02
Last Update Date:2010-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP2978101YP2500X
MDLC3697101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD816700100Medicaid