Provider Demographics
NPI:1083481394
Name:SMITH, SAMUEL LAROY (LMHCA)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:LAROY
Last Name:SMITH
Suffix:
Gender:M
Credentials:LMHCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5622 PACIFIC AVE SE STE 1
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98503-1271
Mailing Address - Country:US
Mailing Address - Phone:360-888-0401
Mailing Address - Fax:
Practice Address - Street 1:5622 PACIFIC AVE SE STE 1
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-1271
Practice Address - Country:US
Practice Address - Phone:360-888-0401
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-06
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61425227101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health