MEDICARE: LARUE MCNISH-SMITH LADC

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	1183	CT

General Provider Information

NPI Number	:	1366805616
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LARUE MCNISH-SMITH LADC

Provider Business Mailing Address
First Line	:	100 MAIN ST N
Second Line	:	SUITE 725
City	:	SOUTHBURY
State	:	CT
Zip	:	06488-3840
Country	:	US
Telephone Number	:	203-681-1212
Fax Number	:	203-519-7979

Provider Business Practice Location Address
First Line	:	100 MAIN ST N
Second Line	:	SUITE 725
City	:	SOUTHBURY
State	:	CT
Zip	:	06488-3840
Country	:	US
Telephone Number	:	203-681-1212
Fax Number	:	203-519-7979

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

Provider Enumeration Date	:	04/04/2016
Last Update Date	:	04/04/2016

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