Healthcare Provider Details

I. General information

NPI: 1275298531
Provider Name (Legal Business Name): STEVEN SMITH LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2021
Last Update Date: 04/16/2023
Certification Date: 04/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 1ST ST W
BEMIDJI MN
56601-4002
US

IV. Provider business mailing address

215 PAUL BUNYAN DR NW STE 133
BEMIDJI MN
56601-2433
US

V. Phone/Fax

Practice location:
  • Phone: 218-888-8032
  • Fax: 218-888-8033
Mailing address:
  • Phone: 218-508-2684
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number31296
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberBBH-LCSW-LIC-50627
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: