MEDICARE: MRS. GINA M SMITH LPCC-SUPV

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	090627	OH
2	101YM0800X	Mental Health Counselor	E.0500056 SUPV	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	090627	OTHER	OH	CDCA
2	E.0500056 SUPV	OTHER	OH	LPCC

General Provider Information

NPI Number	:	1538478052
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. GINA M SMITH LPCC-SUPV

Provider Business Mailing Address
First Line	:	3103 DIXIE HWY
Second Line	:
City	:	HAMILTON
State	:	OH
Zip	:	45015-1653
Country	:	US
Telephone Number	:	513-892-4673
Fax Number	:	513-737-1107

Provider Business Practice Location Address
First Line	:	6570 SOSNA DR
Second Line	:
City	:	FAIRFIELD
State	:	OH
Zip	:	45014-2222
Country	:	US
Telephone Number	:	513-942-4673
Fax Number	:	513-737-1107

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

Provider Enumeration Date	:	10/01/2010
Last Update Date	:	05/18/2022

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