Provider Demographics
NPI:1336296458
Name:SMITH, MARK WARREN (LCSW)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:WARREN
Last Name:SMITH
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:819 E 64TH ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46220-1671
Mailing Address - Country:US
Mailing Address - Phone:317-251-5504
Mailing Address - Fax:317-251-1691
Practice Address - Street 1:819 E 64TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46220-1671
Practice Address - Country:US
Practice Address - Phone:317-251-5504
Practice Address - Fax:317-251-1691
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34000746A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000345326OtherANTHEM ID NUMBER
IN215430Medicare ID - Type Unspecified