Provider Demographics
NPI:1972093870
Name:SMITH, ELLEN (PHD)
Entity type:Individual
Prefix:DR
First Name:ELLEN
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 MOUNTAIN ST
Mailing Address - Street 2:
Mailing Address - City:HAYDENVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:01039-9723
Mailing Address - Country:US
Mailing Address - Phone:413-387-7191
Mailing Address - Fax:
Practice Address - Street 1:60 MOUNTAIN ST
Practice Address - Street 2:
Practice Address - City:HAYDENVILLE
Practice Address - State:MA
Practice Address - Zip Code:01039-9723
Practice Address - Country:US
Practice Address - Phone:413-387-7191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-16
Last Update Date:2018-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1113641041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical