Provider Demographics
NPI:1396381711
Name:SMITH, ANGELA MARIE (LISW-S, LICDC, CFRC)
Entity Type:Individual
Prefix:MS
First Name:ANGELA
Middle Name:MARIE
Last Name:SMITH
Suffix:
Gender:F
Credentials:LISW-S, LICDC, CFRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:OH
Mailing Address - Zip Code:44057-3125
Mailing Address - Country:US
Mailing Address - Phone:440-428-0118
Mailing Address - Fax:440-417-0119
Practice Address - Street 1:15 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:OH
Practice Address - Zip Code:44057-3125
Practice Address - Country:US
Practice Address - Phone:440-413-3392
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-20
Last Update Date:2023-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.20023661041C0700X
OH161774101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0380450Medicaid