Healthcare Provider Details

I. General information

NPI: 1568008282
Provider Name (Legal Business Name): LATRECE SMITH MSW LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2019
Last Update Date: 11/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1270 NORTH AND SOUTH ROAD
ST. LOUIS MO
63130
US

IV. Provider business mailing address

1270 NORTH AND SOUTH ROAD
ST. LOUIS MO
63130
US

V. Phone/Fax

Practice location:
  • Phone: 314-485-9241
  • Fax:
Mailing address:
  • Phone: 314-485-9241
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2019041410
License Number StateMO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: