Healthcare Provider Details

I. General information

NPI: 1194005306
Provider Name (Legal Business Name): EVELYN V SMITH LSCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2011
Last Update Date: 01/03/2023
Certification Date: 01/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 W 8TH ST
COFFEYVILLE KS
67337-4109
US

IV. Provider business mailing address

PO BOX 1832
PITTSBURG KS
66762-1832
US

V. Phone/Fax

Practice location:
  • Phone: 620-251-4300
  • Fax: 620-251-4979
Mailing address:
  • Phone: 620-231-9873
  • Fax: 620-231-5062

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLMSW5111
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number4128
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: