Healthcare Provider Details

I. General information

NPI: 1538478052
Provider Name (Legal Business Name): GINA M SMITH LPCC-SUPV
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2010
Last Update Date: 05/18/2022
Certification Date: 05/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6570 SOSNA DR
FAIRFIELD OH
45014-2222
US

IV. Provider business mailing address

3103 DIXIE HWY
HAMILTON OH
45015-1653
US

V. Phone/Fax

Practice location:
  • Phone: 513-942-4673
  • Fax: 513-737-1107
Mailing address:
  • Phone: 513-892-4673
  • Fax: 513-737-1107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number090627
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberE.0500056 SUPV
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: