Provider Demographics
NPI:1437334703
Name:SMITH, CARLY NICOLE (BA)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:NICOLE
Last Name:SMITH
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 HEALTH CARE LN
Mailing Address - Street 2:P.O. 517
Mailing Address - City:MARSHALL
Mailing Address - State:NC
Mailing Address - Zip Code:28753-6350
Mailing Address - Country:US
Mailing Address - Phone:828-649-2367
Mailing Address - Fax:828-649-3859
Practice Address - Street 1:140 HEALTH CARE LN
Practice Address - Street 2:P.O. 517
Practice Address - City:MARSHALL
Practice Address - State:NC
Practice Address - Zip Code:28753-6350
Practice Address - Country:US
Practice Address - Phone:828-649-2367
Practice Address - Fax:828-649-3859
Is Sole Proprietor?:No
Enumeration Date:2008-01-07
Last Update Date:2008-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8301778BMedicaid