Provider Demographics
NPI:1114446002
Name:SMITH, MATTHEW R (LPCA, LCASA, NCC)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:R
Last Name:SMITH
Suffix:
Gender:M
Credentials:LPCA, LCASA, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 REHOBETH RD
Mailing Address - Street 2:
Mailing Address - City:WAXHAW
Mailing Address - State:NC
Mailing Address - Zip Code:28173-8641
Mailing Address - Country:US
Mailing Address - Phone:704-954-8295
Mailing Address - Fax:
Practice Address - Street 1:1801 E 5TH ST STE 208
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-3400
Practice Address - Country:US
Practice Address - Phone:704-954-8295
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-12
Last Update Date:2017-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC23855101YA0400X
NCA13592101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)