=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508282666
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SMITH THERAPY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/13/2014
-----------------------------------------------------
Last Update Date | 03/13/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1800 N CHARLES ST SUITE 204
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21201-5920
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-869-6584
-----------------------------------------------------
Fax | 443-869-6127
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1800 N CHARLES ST SUITE 204
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21201-5920
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-869-6584
-----------------------------------------------------
Fax | 443-869-6127
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MS. ANN VIRGINIA SMITH
-----------------------------------------------------
Credential | LCSW-C
-----------------------------------------------------
Telephone | 443-869-6584
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 09775
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------