Healthcare Provider Details

I. General information

NPI: 1083112650
Provider Name (Legal Business Name): PHYLLIS MARIE SMITH LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/29/2018
Last Update Date: 01/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1395 AIRPORT RD
MAGEE MS
39111-5367
US

IV. Provider business mailing address

1395 AIRPORT RD
MAGEE MS
39111-5367
US

V. Phone/Fax

Practice location:
  • Phone: 601-434-7665
  • Fax:
Mailing address:
  • Phone: 601-434-7665
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC7830
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: