MEDICARE: MRS. MARIANNE SMITH LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	11739	AZ

General Provider Information

NPI Number	:	1669134342
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MARIANNE SMITH LPC

Provider Business Mailing Address
First Line	:	17043 N 66TH AVE
Second Line	:
City	:	GLENDALE
State	:	AZ
Zip	:	85308-3625
Country	:	US
Telephone Number	:	602-400-2195
Fax Number	:

Provider Business Practice Location Address
First Line	:	17043 N 66TH AVE
Second Line	:
City	:	GLENDALE
State	:	AZ
Zip	:	85308-3625
Country	:	US
Telephone Number	:	602-400-2195
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/09/2021
Last Update Date	:	10/09/2021

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