Healthcare Provider Details

I. General information

NPI: 1073911913
Provider Name (Legal Business Name): MARCUS SMITH LPCC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/09/2014
Last Update Date: 12/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3017 N PRINCE ST STE B
CLOVIS NM
88101-3804
US

IV. Provider business mailing address

517 ROSEWOOD DR
CLOVIS NM
88101-9325
US

V. Phone/Fax

Practice location:
  • Phone: 575-749-2792
  • Fax: 888-276-3843
Mailing address:
  • Phone: 575-749-2792
  • Fax: 888-276-3843

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0163181
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: