MEDICARE: BURRY AND SMITH COUNSELING SERVICES INC.

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	101YM0800X	Mental Health Counselor	34002738A	IN

General Provider Information

NPI Number	:	1902823891
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BURRY AND SMITH COUNSELING SERVICES INC.

Provider Business Mailing Address
First Line	:	3266 MALLARD COVE LN
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-2883
Country	:	US
Telephone Number	:
Fax Number	:	260-436-5986

Provider Business Practice Location Address
First Line	:	3266 MALLARD COVE LN
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-2883
Country	:	US
Telephone Number	:	260-436-5986
Fax Number	:	260-436-5986

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MRS. KIM MARIE SMITH
Credential	:	M. S.,LCSW,LMFC
Telephone Number	:	260-436-5986

Provider Enumeration Date	:	07/16/2006
Last Update Date	:	08/22/2020

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