Healthcare Provider Details

I. General information

NPI: 1508689175
Provider Name (Legal Business Name): JOHNATHAN BAILEY-SMITH LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/04/2024
Last Update Date: 11/04/2024
Certification Date: 11/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3785 NEW TOWN BLVD
SAINT CHARLES MO
63301-4358
US

IV. Provider business mailing address

1800 COMMUNITY
CLINTON MO
64735-8804
US

V. Phone/Fax

Practice location:
  • Phone: 844-853-8937
  • Fax:
Mailing address:
  • Phone: 844-853-8937
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number2024032656
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: