Provider Demographics
NPI:1407903677
Name:SMYTH, CHARLOTTE MARIE (BA)
Entity Type:Individual
Prefix:MISS
First Name:CHARLOTTE
Middle Name:MARIE
Last Name:SMYTH
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:368 NE WASHINGTON AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98532-2615
Mailing Address - Country:US
Mailing Address - Phone:360-748-3034
Mailing Address - Fax:
Practice Address - Street 1:135 W MAIN ST
Practice Address - Street 2:
Practice Address - City:CHEHALIS
Practice Address - State:WA
Practice Address - Zip Code:98532-4817
Practice Address - Country:US
Practice Address - Phone:360-748-6696
Practice Address - Fax:360-748-0627
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARC00045198101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health