=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811423999
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JILL SMITH THERAPY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/10/2017
-----------------------------------------------------
Last Update Date | 05/10/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 570 HARBOR HEIGHTS DR
-----------------------------------------------------
City | LEXINGTON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29072-9369
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-530-9994
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 130 GIBSON RD
-----------------------------------------------------
City | LEXINGTON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29072-3429
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-530-9994
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PSYCHOTHERAPIST
-----------------------------------------------------
Name | MRS. JULIA H SMITH
-----------------------------------------------------
Credential | LISW-CP
-----------------------------------------------------
Telephone | 803-530-9994
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 006653
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------