Provider Demographics
NPI:1417215997
Name:SMITH, PAULA (LMSW)
Entity Type:Individual
Prefix:
First Name:PAULA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2420 E 25TH ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7549
Mailing Address - Country:US
Mailing Address - Phone:208-542-1026
Mailing Address - Fax:208-528-2945
Practice Address - Street 1:1070 HILINE RD
Practice Address - Street 2:STE 210
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-2947
Practice Address - Country:US
Practice Address - Phone:208-478-9081
Practice Address - Fax:208-478-4999
Is Sole Proprietor?:No
Enumeration Date:2012-05-02
Last Update Date:2012-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-31956104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker