Healthcare Provider Details

I. General information

NPI: 1700130846
Provider Name (Legal Business Name): DESTA SUE SMITH MA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/27/2012
Last Update Date: 10/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1327 S 18TH ST
NEW CASTLE IN
47362-2665
US

IV. Provider business mailing address

301 W MEMORIAL DR
MUNCIE IN
47302-3202
US

V. Phone/Fax

Practice location:
  • Phone: 765-593-0003
  • Fax: 765-593-0032
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: