MEDICARE: LINDA C SMITH 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	106H00000X	Marriage & Family Therapist	35001446A	IN
2	101Y00000X	Counselor	39000209A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	267336000	OTHER	MAGELLAN BEHAVIORAL HEALT
2	000000311148	OTHER	ANTHEM
3	0007789215	OTHER	AETNA US HEALTHCARE
4	2043493	OTHER	CIGNA

General Provider Information

NPI Number	:	1568457737
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LINDA C SMITH LMFT LMHC

Provider Business Mailing Address
First Line	:	6413 CONSTITUTION DR
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-1549
Country	:	US
Telephone Number	:	260-755-5495
Fax Number	:	260-755-5947

Provider Business Practice Location Address
First Line	:	6413 CONSTITUTION DR
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-1549
Country	:	US
Telephone Number	:	260-755-5495
Fax Number	:	260-755-5947

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

Provider Enumeration Date	:	09/14/2005
Last Update Date	:	10/27/2017

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