Healthcare Provider Details

I. General information

NPI: 1194963629
Provider Name (Legal Business Name): MARY ELLEN SMITH LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/21/2009
Last Update Date: 01/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

847 STATE ST
GASSAWAY WV
26624-9303
US

IV. Provider business mailing address

RR 1 BOX 108
FRAMETOWN WV
26623-9740
US

V. Phone/Fax

Practice location:
  • Phone: 304-364-8113
  • Fax:
Mailing address:
  • Phone: 304-364-5571
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number2008-2502
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: