=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629965843
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CORONDIUS ANTHONY SMITH LMSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/20/2025
-----------------------------------------------------
Last Update Date | 06/20/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1703 N LOOP 1604 W APT 4205
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78258-4688
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-304-4958
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1703 N LOOP 1604 W APT 4205
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78258-4688
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-304-4958
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 116383
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------