Provider Demographics
NPI:1083112650
Name:SMITH, PHYLLIS MARIE (LCSW)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:MARIE
Last Name:SMITH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1395 AIRPORT RD
Mailing Address - Street 2:
Mailing Address - City:MAGEE
Mailing Address - State:MS
Mailing Address - Zip Code:39111-5367
Mailing Address - Country:US
Mailing Address - Phone:601-434-7665
Mailing Address - Fax:
Practice Address - Street 1:1395 AIRPORT RD
Practice Address - Street 2:
Practice Address - City:MAGEE
Practice Address - State:MS
Practice Address - Zip Code:39111-5367
Practice Address - Country:US
Practice Address - Phone:601-434-7665
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-29
Last Update Date:2018-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSC78301041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty