Provider Demographics
NPI:1467034298
Name:SMITH, OCTAVIA MICHELLE (LMSW)
Entity Type:Individual
Prefix:
First Name:OCTAVIA
Middle Name:MICHELLE
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 1:8325 JACOBS RD
Mailing Address - Street 2:
Mailing Address - City:SEVERN
Mailing Address - State:MD
Mailing Address - Zip Code:21144-2903
Mailing Address - Country:US
Mailing Address - Phone:240-755-9399
Mailing Address - Fax:
Practice Address - Street 1:10632 LITTLE PATUXENT PKWY
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21044-3273
Practice Address - Country:US
Practice Address - Phone:443-995-5984
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-21
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD24335104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker