Provider Demographics
NPI:1093381634
Name:SMITH, THERESA (LSCSW)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:LSCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:313 S MARKET ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67202-3805
Mailing Address - Country:US
Mailing Address - Phone:316-265-9441
Mailing Address - Fax:316-265-6066
Practice Address - Street 1:313 S MARKET ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67202-3805
Practice Address - Country:US
Practice Address - Phone:316-265-9441
Practice Address - Fax:316-265-6066
Is Sole Proprietor?:No
Enumeration Date:2021-06-03
Last Update Date:2021-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS74561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical