=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013409994
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | REESA SMITH LMFT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/05/2018
-----------------------------------------------------
Last Update Date | 01/18/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 412 S. MAPLE ST. SUITE 100B
-----------------------------------------------------
City | FORTVILLE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46040
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 765-276-7131
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9249 W SWIMMING HOLE LN
-----------------------------------------------------
City | PENDLETON
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46064-8659
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 765-610-9864
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 35002048A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------