MEDICARE: SAMUEL M. SMITH, MA, LMFT, LMHC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	35001463A	IN

General Provider Information

NPI Number	:	1104018985
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAMUEL M. SMITH, MA, LMFT, LMHC

Provider Business Mailing Address
First Line	:	4920 COMMON VISTA CT
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46220-5394
Country	:	US
Telephone Number	:	317-466-9809
Fax Number	:	317-466-9809

Provider Business Practice Location Address
First Line	:	4920 COMMON VISTA CT
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46220-5394
Country	:	US
Telephone Number	:	317-466-9809
Fax Number	:	317-466-9809

Authorized Official
Title or Position	:	MARRIAGE & FAMILY THERAPIST
Name	:	MR. SAMUEL MARK SMITH
Credential	:	MA, LMFT, LMHC
Telephone Number	:	317-466-9809

Provider Enumeration Date	:	08/15/2007
Last Update Date	:	08/15/2007

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