Provider Demographics
NPI:1538523154
Name:SMOOK, MAVIS LAUREN
Entity type:Individual
Prefix:
First Name:MAVIS
Middle Name:LAUREN
Last Name:SMOOK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6725 CLYDE ST
Mailing Address - Street 2:2M
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-4056
Mailing Address - Country:US
Mailing Address - Phone:347-907-1210
Mailing Address - Fax:
Practice Address - Street 1:6725 CLYDE ST
Practice Address - Street 2:2M
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-4056
Practice Address - Country:US
Practice Address - Phone:718-263-5653
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-09
Last Update Date:2016-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY103K00000X103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst