Provider Demographics
NPI:1427203157
Name:SMITH, THEODORE VANDIX III (LMSW)
Entity type:Individual
Prefix:MR
First Name:THEODORE
Middle Name:VANDIX
Last Name:SMITH
Suffix:III
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102-32 189TH STREET
Mailing Address - Street 2:
Mailing Address - City:HOLLIS
Mailing Address - State:NY
Mailing Address - Zip Code:11423
Mailing Address - Country:US
Mailing Address - Phone:718-454-2152
Mailing Address - Fax:
Practice Address - Street 1:71-50 PARSONS BLVD.
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11365
Practice Address - Country:US
Practice Address - Phone:718-591-6750
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-21
Last Update Date:2008-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY068663-1101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health