Provider Demographics
NPI:1013221407
Name:SMITH, MARVIN LEIGH (ISW)
Entity Type:Individual
Prefix:
First Name:MARVIN
Middle Name:LEIGH
Last Name:SMITH
Suffix:
Gender:M
Credentials:ISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 E MAUD ST
Mailing Address - Street 2:
Mailing Address - City:TAVARES
Mailing Address - State:FL
Mailing Address - Zip Code:32778-3249
Mailing Address - Country:US
Mailing Address - Phone:352-253-9348
Mailing Address - Fax:352-253-9351
Practice Address - Street 1:101 E MAUD ST
Practice Address - Street 2:
Practice Address - City:TAVARES
Practice Address - State:FL
Practice Address - Zip Code:32778-3249
Practice Address - Country:US
Practice Address - Phone:352-253-9348
Practice Address - Fax:352-253-9351
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-28
Last Update Date:2013-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW111331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical