Provider Demographics
NPI:1396060273
Name:SMITH, COREY D (PSYD)
Entity type:Individual
Prefix:
First Name:COREY
Middle Name:D
Last Name:SMITH
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:149 NORTH ST
Mailing Address - Street 2:
Mailing Address - City:WATERVILLE
Mailing Address - State:ME
Mailing Address - Zip Code:04901-4974
Mailing Address - Country:US
Mailing Address - Phone:207-861-5000
Mailing Address - Fax:207-861-5001
Practice Address - Street 1:149 NORTH ST
Practice Address - Street 2:
Practice Address - City:WATERVILLE
Practice Address - State:ME
Practice Address - Zip Code:04901-4974
Practice Address - Country:US
Practice Address - Phone:207-861-5000
Practice Address - Fax:207-861-5001
Is Sole Proprietor?:No
Enumeration Date:2010-04-02
Last Update Date:2015-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE683103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical