=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629079223
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHAEL SMITH LPC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/03/2005
-----------------------------------------------------
Last Update Date | 04/19/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1519 RAINBOW DR
-----------------------------------------------------
City | GADSDEN
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35901-5326
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 256-459-8255
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 7052
-----------------------------------------------------
City | GADSDEN
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35906-7052
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 256-393-2463
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 2017
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------