Healthcare Provider Details

I. General information

NPI: 1366007536
Provider Name (Legal Business Name): GWENDOLYN MARIE SMITH LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: GWEN SMITH

II. Dates (important events)

Enumeration Date: 05/03/2019
Last Update Date: 05/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3535 KNIGHT LN TRLR 8
LAKE CHARLES LA
70605-1233
US

IV. Provider business mailing address

PO BOX 13047
LAKE CHARLES LA
70612-3047
US

V. Phone/Fax

Practice location:
  • Phone: 337-986-9197
  • Fax: 337-588-4179
Mailing address:
  • Phone: 337-855-9023
  • Fax: 337-855-1829

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number15513
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number15235
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: