Provider Demographics
NPI:1336500677
Name:SMITH, GARY (LPCC-S)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:LPCC-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1515 INDIANOLA AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43201-2118
Mailing Address - Country:US
Mailing Address - Phone:614-294-2661
Mailing Address - Fax:614-294-3247
Practice Address - Street 1:1515 INDIANOLA AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43201-2118
Practice Address - Country:US
Practice Address - Phone:614-294-2661
Practice Address - Fax:614-294-3247
Is Sole Proprietor?:No
Enumeration Date:2016-03-15
Last Update Date:2016-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE.0004074101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health