Provider Demographics
NPI:1962743211
Name:SMITH, THERESA M (MS ED)
Entity type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:M
Last Name:SMITH
Suffix:
Gender:F
Credentials:MS ED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 N MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12206-1821
Mailing Address - Country:US
Mailing Address - Phone:518-437-6735
Mailing Address - Fax:518-437-6532
Practice Address - Street 1:160 N MAIN AVE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12206-1821
Practice Address - Country:US
Practice Address - Phone:518-437-6735
Practice Address - Fax:518-437-6532
Is Sole Proprietor?:No
Enumeration Date:2013-03-12
Last Update Date:2013-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1138706174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1138706OtherNYS TEACHER CERTIFICATION