MEDICARE: MR. LARRY JOSEPH SMITH JR. NBCC

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	101Y00000X	Counselor

General Provider Information

NPI Number	:	1275905051
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. LARRY JOSEPH SMITH JR. NBCC

Provider Business Mailing Address
First Line	:	827 OLD SPANISH TRL
Second Line	:
City	:	BAY ST LOUIS
State	:	MS
Zip	:	39520-2204
Country	:	US
Telephone Number	:	228-467-8203
Fax Number	:	228-467-8203

Provider Business Practice Location Address
First Line	:	827 OLD SPANISH TRL
Second Line	:
City	:	BAY ST LOUIS
State	:	MS
Zip	:	39520-2204
Country	:	US
Telephone Number	:	228-467-8203
Fax Number	:	228-467-8203

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/20/2015
Last Update Date	:	10/20/2015

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