Provider Demographics
NPI:1003836743
Name:SMITH, MARY MAGDALENE (MA)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:MAGDALENE
Last Name:SMITH
Suffix:
Gender:F
Credentials:MA
Other - Prefix:MRS
Other - First Name:MAGDALENA
Other - Middle Name:SOLANO
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA
Mailing Address - Street 1:1380 RIVER BEND DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75247-4914
Mailing Address - Country:US
Mailing Address - Phone:214-743-1272
Mailing Address - Fax:214-743-1272
Practice Address - Street 1:1353 N WESTMORELAND RD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75211-1655
Practice Address - Country:US
Practice Address - Phone:469-387-5001
Practice Address - Fax:469-387-5001
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2016-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX8385101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX174950901Medicaid