Provider Demographics
NPI:1265599682
Name:SMITH, SUSANNAH (PHD)
Entity type:Individual
Prefix:DR
First Name:SUSANNAH
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:PO BOX 3258
Mailing Address - Street 2:
Mailing Address - City:TELLURIDE
Mailing Address - State:CO
Mailing Address - Zip Code:81435-3258
Mailing Address - Country:US
Mailing Address - Phone:970-728-5234
Mailing Address - Fax:
Practice Address - Street 1:747 PACIFIC ST.
Practice Address - Street 2:421
Practice Address - City:TELLURIDE
Practice Address - State:CO
Practice Address - Zip Code:81435
Practice Address - Country:US
Practice Address - Phone:970-728-5234
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2011-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1830103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO02680874Medicaid
CO83936Medicare ID - Type Unspecified