Provider Demographics
NPI:1427420108
Name:SMIRTHWAITE, SARAH SUZANNE
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:SUZANNE
Last Name:SMIRTHWAITE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SARAH
Other - Middle Name:SUZANNE
Other - Last Name:DYKES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:8990 LORRAINE RD
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-4176
Mailing Address - Country:US
Mailing Address - Phone:228-331-3310
Mailing Address - Fax:228-284-1608
Practice Address - Street 1:8990 LORRAINE RD
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-4176
Practice Address - Country:US
Practice Address - Phone:228-331-3310
Practice Address - Fax:228-284-1608
Is Sole Proprietor?:No
Enumeration Date:2015-10-21
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSC73931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08685769Medicaid