Provider Demographics
NPI:1275141269
Name:SMITH, TERRY (BSW)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:BSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2305
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MS
Mailing Address - Zip Code:39060-2305
Mailing Address - Country:US
Mailing Address - Phone:601-927-0188
Mailing Address - Fax:
Practice Address - Street 1:901 HIGHWAY 80 E
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MS
Practice Address - Zip Code:39056-5244
Practice Address - Country:US
Practice Address - Phone:601-927-0188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-16
Last Update Date:2020-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02551264Medicaid