MEDICARE: DR. CAROL YVONNE SMITH PHD, PHD, MS, LICSW,

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	12946	WI
2	103TC0700X	Clinical Psychologist	3503	NC
3	1041C0700X	Clinical Social Worker	4272-123	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1326044546
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CAROL YVONNE SMITH PHD, PHD, MS, LICSW,

Provider Business Mailing Address
First Line	:	PO BOX 4
Second Line	:
City	:	JACKSON SPRINGS
State	:	NC
Zip	:	27281-0004
Country	:	US
Telephone Number	:	414-975-9908
Fax Number	:	910-673-5775

Provider Business Practice Location Address
First Line	:	1107 SEVEN LAKES DRIVE
Second Line	:
City	:	SEVEN LAKES
State	:	NC
Zip	:	27376-0000
Country	:	US
Telephone Number	:	910-778-2427
Fax Number	:	910-673-5775

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

Provider Enumeration Date	:	06/22/2005
Last Update Date	:	03/30/2009

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