Provider Demographics
NPI:1245216837
Name:SMITH, MARK L (LPC, LCSW)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:L
Last Name:SMITH
Suffix:
Gender:M
Credentials:LPC, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8003 KENWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64131-2147
Mailing Address - Country:US
Mailing Address - Phone:816-353-5363
Mailing Address - Fax:816-295-6100
Practice Address - Street 1:14825 E 42ND ST S
Practice Address - Street 2:SUITE 208
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64055-4776
Practice Address - Country:US
Practice Address - Phone:816-353-5363
Practice Address - Fax:816-295-6100
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-16
Last Update Date:2014-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO000226101YP2500X
MO0023261041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOA958082OtherVALUE OPTIONS
MO34942019OtherBLUE CROSS BLUE SHIELD
MO34942OtherPREFERRED HEALTH
MO493295521Medicaid
MA14787001OtherMEDICARE INDIVIDUAL PTAN MA14787001
1669617627OtherGROUP NPI
MA1478OtherMEDICARE GROUP