Provider Demographics
NPI:1215094917
Name:SMUCKER, MERVIN R (PHD)
Entity type:Individual
Prefix:DR
First Name:MERVIN
Middle Name:R
Last Name:SMUCKER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 CARTER RD
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46526-5201
Mailing Address - Country:US
Mailing Address - Phone:414-403-4949
Mailing Address - Fax:574-537-0567
Practice Address - Street 1:6110 N PORT WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53217-4308
Practice Address - Country:US
Practice Address - Phone:414-403-4949
Practice Address - Fax:574-537-0567
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1538-057103TC0700X
IN20041542103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI84338Medicare ID - Type Unspecified