Healthcare Provider Details

I. General information

NPI: 1255844627
Provider Name (Legal Business Name): IBEN S SMITH LSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2017
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3616 EAST MAIN ST
COLUMBUS OH
43213-2913
US

IV. Provider business mailing address

3616 EAST MAIN STREET
COLUMBUS OH
43213
US

V. Phone/Fax

Practice location:
  • Phone: 614-251-0103
  • Fax: 614-251-1177
Mailing address:
  • Phone: 614-251-0103
  • Fax: 614-251-1177

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: