Provider Demographics
NPI:1013037464
Name:SMITH, WALTER JAMES (MA, LCPC, NCC)
Entity Type:Individual
Prefix:MR
First Name:WALTER
Middle Name:JAMES
Last Name:SMITH
Suffix:
Gender:M
Credentials:MA, LCPC, NCC
Other - Prefix:MR
Other - First Name:W.
Other - Middle Name:JAMES
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA, LCPC, NCC
Mailing Address - Street 1:PO BOX 1992
Mailing Address - Street 2:
Mailing Address - City:RED LODGE
Mailing Address - State:MT
Mailing Address - Zip Code:59068-1992
Mailing Address - Country:US
Mailing Address - Phone:406-672-6289
Mailing Address - Fax:406-446-2114
Practice Address - Street 1:4 HARNISH LANE
Practice Address - Street 2:
Practice Address - City:RED LODGE
Practice Address - State:MT
Practice Address - Zip Code:59068-1992
Practice Address - Country:US
Practice Address - Phone:406-671-6289
Practice Address - Fax:406-446-2114
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTLCPC 40101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0252297Medicaid
MT07547-0OtherMT BLUECROSS BLUESHIELD