Provider Demographics
NPI:1053515361
Name:SMITH, PAMELA LONGFELLOW (PSYD)
Entity type:Individual
Prefix:DR
First Name:PAMELA
Middle Name:LONGFELLOW
Last Name:SMITH
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:PAMELA
Other - Middle Name:LONGFELLOW
Other - Last Name:BLUME
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:1734 DOGWOOD DR
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22302-2324
Mailing Address - Country:US
Mailing Address - Phone:571-970-2633
Mailing Address - Fax:
Practice Address - Street 1:9501 FARRELL RD STE GC-11
Practice Address - Street 2:
Practice Address - City:FORT BELVOIR
Practice Address - State:VA
Practice Address - Zip Code:22060-5901
Practice Address - Country:US
Practice Address - Phone:571-970-2633
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810003789103TC0700X
DC1000392103TC0700X
HI962103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical