Healthcare Provider Details

I. General information

NPI: 1386181170
Provider Name (Legal Business Name): SUSAN SMOTHERS LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2017
Last Update Date: 01/31/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1305 WEST MAIN STREET
MARION IL
62959
US

IV. Provider business mailing address

44 VANTAGE WAY SUITE 400
NASHVILLE TN
37228-1513
US

V. Phone/Fax

Practice location:
  • Phone: 855-608-3560
  • Fax:
Mailing address:
  • Phone: 615-463-6658
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180.001401
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: