Healthcare Provider Details

I. General information

NPI: 1124613005
Provider Name (Legal Business Name): SAMANTHA JANE SMITH LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/03/2021
Last Update Date: 04/14/2023
Certification Date: 04/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11166 TESSON FERRY RD STE 300
SAINT LOUIS MO
63123-6966
US

IV. Provider business mailing address

2650 OLIVE ST
SAINT LOUIS MO
63103-1489
US

V. Phone/Fax

Practice location:
  • Phone: 314-802-2658
  • Fax: 314-842-2552
Mailing address:
  • Phone: 314-371-6500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: