Healthcare Provider Details

I. General information

NPI: 1124531397
Provider Name (Legal Business Name): MARY F SMITH LPC-S, LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2017
Last Update Date: 04/14/2020
Certification Date: 04/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N 13TH ST
PONCHATOULA LA
70454
US

IV. Provider business mailing address

100 N 13TH ST
PONCHATOULA LA
70454
US

V. Phone/Fax

Practice location:
  • Phone: 985-517-7034
  • Fax:
Mailing address:
  • Phone: 985-517-7034
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2724
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number851
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: