Provider Demographics
NPI:1093836553
Name:SMITH, MARY LOU (LCSW & LSAC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LOU
Last Name:SMITH
Suffix:
Gender:F
Credentials:LCSW & LSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84097-7028
Mailing Address - Country:US
Mailing Address - Phone:801-224-3322
Mailing Address - Fax:801-224-3848
Practice Address - Street 1:900 S STATE ST
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84097-7028
Practice Address - Country:US
Practice Address - Phone:801-224-3322
Practice Address - Fax:801-224-3848
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT314648-6006101YA0400X
UT314648-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical