Provider Demographics
NPI:1003252743
Name:SMITH, ELIZABETH ANN
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ANN
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:ANN
Other - Last Name:WAGENAAR-SMITH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:2113 GOVERNEMTN ST STE B-4
Mailing Address - Street 2:
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39564
Mailing Address - Country:US
Mailing Address - Phone:228-875-6400
Mailing Address - Fax:228-875-6400
Practice Address - Street 1:2113 GOVERNMENT ST STE B4
Practice Address - Street 2:
Practice Address - City:OCEAN SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39564-3949
Practice Address - Country:US
Practice Address - Phone:228-875-6400
Practice Address - Fax:228-875-6400
Is Sole Proprietor?:No
Enumeration Date:2013-05-21
Last Update Date:2013-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1768101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor