Healthcare Provider Details

I. General information

NPI: 1972804474
Provider Name (Legal Business Name): MARIA L SMITH PMHNP-BC, C-FNP, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/15/2010
Last Update Date: 10/14/2022
Certification Date: 10/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 SOUTHLAKE CIR
CANTON MS
39046-5369
US

IV. Provider business mailing address

1101 KENWOOD PL
JACKSON MS
39202-2432
US

V. Phone/Fax

Practice location:
  • Phone: 601-824-0342
  • Fax:
Mailing address:
  • Phone: 601-951-0493
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number902088
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number902088
License Number StateMS
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number1056
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: