=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154672202
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RODERICK JAMES SMITH LPC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/28/2012
-----------------------------------------------------
Last Update Date | 02/24/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 440 BENMAR DR STE 1035
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77060
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-858-3974
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 66308
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77266-6308
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-548-5076
-----------------------------------------------------
Fax | 713-523-4897
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 67276
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------