Provider Demographics
NPI:1417474172
Name:SMITH, COURTNEY
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:703 CALVIN AVERY DR
Mailing Address - Street 2:
Mailing Address - City:WEST MEMPHIS
Mailing Address - State:AR
Mailing Address - Zip Code:72301-6501
Mailing Address - Country:US
Mailing Address - Phone:870-732-1878
Mailing Address - Fax:870-702-7111
Practice Address - Street 1:2135 MALCOLM AVE
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:AR
Practice Address - Zip Code:72112-3631
Practice Address - Country:US
Practice Address - Phone:870-523-8003
Practice Address - Fax:870-523-8081
Is Sole Proprietor?:No
Enumeration Date:2017-08-24
Last Update Date:2017-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR220961795Medicaid