Healthcare Provider Details

I. General information

NPI: 1275141269
Provider Name (Legal Business Name): TERRY SMITH BSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/16/2020
Last Update Date: 07/16/2020
Certification Date: 07/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 HIGHWAY 80 E
CLINTON MS
39056-5244
US

IV. Provider business mailing address

PO BOX 2305
CLINTON MS
39060-2305
US

V. Phone/Fax

Practice location:
  • Phone: 601-927-0188
  • Fax:
Mailing address:
  • Phone: 601-927-0188
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: