Healthcare Provider Details

I. General information

NPI: 1962547422
Provider Name (Legal Business Name): JOHNNIE L SMITH-SHULL LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2007
Last Update Date: 12/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

85 MECHANIC ST STE 3B-1 DARTMOUTH HITCHCOCK - PSYCHIATRY
LEBANON NH
03766-1537
US

IV. Provider business mailing address

85 MECHANIC ST STE 3B-1 DARTMOUTH HITCHCOCK - PSYCHIATRY
LEBANON NH
03766-1537
US

V. Phone/Fax

Practice location:
  • Phone: 603-653-1732
  • Fax:
Mailing address:
  • Phone: 603-653-1732
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLW00005924
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1513
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: