Healthcare Provider Details

I. General information

NPI: 1194128322
Provider Name (Legal Business Name): ROBERT JAMES SMITH LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2014
Last Update Date: 10/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2434 S EASON BLVD
TUPELO MS
38804-6942
US

IV. Provider business mailing address

2434 S EASON BLVD
TUPELO MS
38804-6942
US

V. Phone/Fax

Practice location:
  • Phone: 662-640-4595
  • Fax: 662-680-5122
Mailing address:
  • Phone: 662-640-4595
  • Fax: 662-680-5122

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC2599
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1787-C
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: