Provider Demographics
NPI:1205062270
Name:SMITH, SCOTT MATTHEW (PHD)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:MATTHEW
Last Name:SMITH
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 2617
Mailing Address - Street 2:
Mailing Address - City:ATASCADERO
Mailing Address - State:CA
Mailing Address - Zip Code:93423-2617
Mailing Address - Country:US
Mailing Address - Phone:805-748-0563
Mailing Address - Fax:
Practice Address - Street 1:5755 VIOLETA AVE
Practice Address - Street 2:
Practice Address - City:ATASCADERO
Practice Address - State:CA
Practice Address - Zip Code:93422-3125
Practice Address - Country:US
Practice Address - Phone:805-748-0563
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-04
Last Update Date:2009-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY15083103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist