Provider Demographics
NPI:1073786000
Name:SMITH, MIRANDA (GSW)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:GSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 395
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:LA
Mailing Address - Zip Code:70722-0395
Mailing Address - Country:US
Mailing Address - Phone:225-683-5292
Mailing Address - Fax:
Practice Address - Street 1:11990 JACKSON ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:LA
Practice Address - Zip Code:70722-0395
Practice Address - Country:US
Practice Address - Phone:225-683-5292
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-10
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA93291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical