Provider Demographics
NPI:1417004920
Name:SMITH, GWEN MARIA (LMHP, LPC, PLADC)
Entity Type:Individual
Prefix:
First Name:GWEN
Middle Name:MARIA
Last Name:SMITH
Suffix:
Gender:F
Credentials:LMHP, LPC, PLADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2286 COUNTY ROAD Q
Mailing Address - Street 2:
Mailing Address - City:WILBER
Mailing Address - State:NE
Mailing Address - Zip Code:68465-2433
Mailing Address - Country:US
Mailing Address - Phone:402-821-2119
Mailing Address - Fax:
Practice Address - Street 1:2286 COUNTY ROAD Q
Practice Address - Street 2:
Practice Address - City:WILBER
Practice Address - State:NE
Practice Address - Zip Code:68465-2433
Practice Address - Country:US
Practice Address - Phone:402-821-2119
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE990101Y00000X
NEP-388101YA0400X
TX6488101YA0400X
NE1614101YM0800X
TX24497104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47052851581Medicaid
NE47052851500Medicaid
NE84442OtherBC/BS