Provider Demographics
NPI:1376853358
Name:SMITH, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1560 S 14TH AVE
Mailing Address - Street 2:
Mailing Address - City:SAFFORD
Mailing Address - State:AZ
Mailing Address - Zip Code:85546-3546
Mailing Address - Country:US
Mailing Address - Phone:928-432-1711
Mailing Address - Fax:
Practice Address - Street 1:919 W THATCHER BLVD
Practice Address - Street 2:
Practice Address - City:SAFFORD
Practice Address - State:AZ
Practice Address - Zip Code:85546-3133
Practice Address - Country:US
Practice Address - Phone:928-792-5146
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-08
Last Update Date:2022-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAMFT-10313106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist