Provider Demographics
NPI:1093282675
Name:SMITH, MARK ALLEN (LMHC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ALLEN
Last Name:SMITH
Suffix:
Gender:M
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14201 SE PETROVITSKY RD STE A3165
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98058-8986
Mailing Address - Country:US
Mailing Address - Phone:425-757-4648
Mailing Address - Fax:
Practice Address - Street 1:14201 SE PETROVITSKY RD STE A3165
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98058-8986
Practice Address - Country:US
Practice Address - Phone:425-757-4648
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-31
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH61149661101YM0800X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health