MEDICARE: MRS. STEPHANIE SMITH LCSW

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	1041C0700X	Clinical Social Worker	C6832	MS

General Provider Information

NPI Number	:	1942527791
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. STEPHANIE SMITH LCSW

Provider Business Mailing Address
First Line	:	118 COLLEGE DR
Second Line	:	PO BOX 5114
City	:	HATTIESBURG
State	:	MS
Zip	:	39406-0002
Country	:	US
Telephone Number	:	601-266-4294
Fax Number	:	601-266-4167

Provider Business Practice Location Address
First Line	:	118 COLLEGE DR
Second Line	:
City	:	HATTIESBURG
State	:	MS
Zip	:	39406-0002
Country	:	US
Telephone Number	:	601-266-4294
Fax Number	:	601-266-4167

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

Provider Enumeration Date	:	05/03/2010
Last Update Date	:	05/03/2010

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