=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104018985
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SAMUEL M. SMITH, MA, LMFT, LMHC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/15/2007
-----------------------------------------------------
Last Update Date | 08/15/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4920 COMMON VISTA CT
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46220-5394
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-466-9809
-----------------------------------------------------
Fax | 317-466-9809
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4920 COMMON VISTA CT
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46220-5394
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-466-9809
-----------------------------------------------------
Fax | 317-466-9809
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MARRIAGE & FAMILY THERAPIST
-----------------------------------------------------
Name | MR. SAMUEL MARK SMITH
-----------------------------------------------------
Credential | MA, LMFT, LMHC
-----------------------------------------------------
Telephone | 317-466-9809
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 35001463A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------