Healthcare Provider Details

I. General information

NPI: 1619513546
Provider Name (Legal Business Name): SAMANTHA SMITH CDCA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/26/2019
Last Update Date: 01/30/2025
Certification Date: 01/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

827 N MAIN ST
MARION OH
43302-1736
US

IV. Provider business mailing address

827 N MAIN ST
MARION OH
43302-1736
US

V. Phone/Fax

Practice location:
  • Phone: 740-442-7045
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License NumberCDCA.170169
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: