Provider Demographics
NPI:1750443651
Name:SMYTH, MICHAEL F (PHD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:F
Last Name:SMYTH
Suffix:
Gender:M
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 572
Mailing Address - Street 2:
Mailing Address - City:GORHAM
Mailing Address - State:ME
Mailing Address - Zip Code:04038-0572
Mailing Address - Country:US
Mailing Address - Phone:207-839-4535
Mailing Address - Fax:
Practice Address - Street 1:800 CENTER ST
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:ME
Practice Address - Zip Code:04210-6404
Practice Address - Country:US
Practice Address - Phone:207-782-2726
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-15
Last Update Date:2009-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPS446103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEMM3584Medicare ID - Type Unspecified