Provider Demographics
NPI:1225328768
Name:SMITH, MARK W (MA, LCPC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:W
Last Name:SMITH
Suffix:
Gender:M
Credentials:MA, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2619 W. 6TH ST.
Mailing Address - Street 2:SUITE C
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66049
Mailing Address - Country:US
Mailing Address - Phone:614-263-8161
Mailing Address - Fax:614-263-8268
Practice Address - Street 1:2619 W. 6TH ST
Practice Address - Street 2:SUITE C
Practice Address - City:LAWRENCE
Practice Address - State:KS
Practice Address - Zip Code:66049
Practice Address - Country:US
Practice Address - Phone:785-830-8299
Practice Address - Fax:614-263-8268
Is Sole Proprietor?:No
Enumeration Date:2011-04-18
Last Update Date:2016-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE.0800480101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional