Healthcare Provider Details

I. General information

NPI: 1245530708
Provider Name (Legal Business Name): PENELOPE A. SMITH M.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/29/2010
Last Update Date: 11/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10466 CHESTNUT RIDGE RD
LYNCHBURG TN
37352-5629
US

IV. Provider business mailing address

10466 CHESTNUT RIDGE RD
LYNCHBURG TN
37352-5629
US

V. Phone/Fax

Practice location:
  • Phone: 931-307-8768
  • Fax: 931-759-5176
Mailing address:
  • Phone: 931-307-8768
  • Fax: 931-759-5176

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberPE0000011688
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: