Healthcare Provider Details

I. General information

NPI: 1174995138
Provider Name (Legal Business Name): LARRY LEE SMITH JR. M.S
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: LARRY LEE SMITH JR. M.S

II. Dates (important events)

Enumeration Date: 10/29/2015
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6015 HEARNE AVENUE
SHREVEPORT LA
71108
US

IV. Provider business mailing address

4827 RICE RD
SHREVEPORT LA
71119
US

V. Phone/Fax

Practice location:
  • Phone: 318-210-7307
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number9611
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number9611
License Number StateLA
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: