Provider Demographics
NPI:1336123918
Name:SMITH, EVELYN M (MA LCMHC)
Entity type:Individual
Prefix:
First Name:EVELYN
Middle Name:M
Last Name:SMITH
Suffix:
Gender:F
Credentials:MA LCMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 136
Mailing Address - Street 2:
Mailing Address - City:SHELBURNE
Mailing Address - State:VT
Mailing Address - Zip Code:05482-0136
Mailing Address - Country:US
Mailing Address - Phone:802-578-0342
Mailing Address - Fax:
Practice Address - Street 1:145 PINE HAVEN SHORES RD STE 2103
Practice Address - Street 2:
Practice Address - City:SHELBURNE
Practice Address - State:VT
Practice Address - Zip Code:05482-7703
Practice Address - Country:US
Practice Address - Phone:802-578-0342
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-06
Last Update Date:2024-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0680000219103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1007117Medicaid