Provider Demographics
NPI:1326044546
Name:SMITH, CAROL YVONNE (PHD, PHD, MS, LICSW,)
Entity Type:Individual
Prefix:DR
First Name:CAROL
Middle Name:YVONNE
Last Name:SMITH
Suffix:
Gender:F
Credentials:PHD, PHD, MS, LICSW,
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 4
Mailing Address - Street 2:
Mailing Address - City:JACKSON SPRINGS
Mailing Address - State:NC
Mailing Address - Zip Code:27281-0004
Mailing Address - Country:US
Mailing Address - Phone:414-975-9908
Mailing Address - Fax:910-673-5775
Practice Address - Street 1:1107 SEVEN LAKES DRIVE
Practice Address - Street 2:
Practice Address - City:SEVEN LAKES
Practice Address - State:NC
Practice Address - Zip Code:27376-0000
Practice Address - Country:US
Practice Address - Phone:910-778-2427
Practice Address - Fax:910-673-5775
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2009-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12946101YA0400X
NC3503103TC0700X
WI4272-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6001053Medicaid
WI39530500Medicaid
NC2821285Medicare PIN
WI39530500Medicaid
WI000184052Medicare PIN