Provider Demographics
NPI:1407990351
Name:SMITH, FAISON HEATHMAN IV (LCDC, ADCIII)
Entity Type:Individual
Prefix:MR
First Name:FAISON
Middle Name:HEATHMAN
Last Name:SMITH
Suffix:IV
Gender:M
Credentials:LCDC, ADCIII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3216 SWALLOW AVE
Mailing Address - Street 2:
Mailing Address - City:MCALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:78504-4925
Mailing Address - Country:US
Mailing Address - Phone:956-630-3405
Mailing Address - Fax:
Practice Address - Street 1:801 W NOLANA AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:MCALLEN
Practice Address - State:TX
Practice Address - Zip Code:78504-3034
Practice Address - Country:US
Practice Address - Phone:956-994-1428
Practice Address - Fax:956-994-1487
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2010-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1765101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8840BHOtherBC-BS