Provider Demographics
NPI:1467540088
Name:SMITH, JAMES LARRY (MS, LP)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:LARRY
Last Name:SMITH
Suffix:
Gender:M
Credentials:MS, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:732 37TH ST SW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55902-1282
Mailing Address - Country:US
Mailing Address - Phone:507-288-7958
Mailing Address - Fax:507-252-5497
Practice Address - Street 1:724 FIRST AVE. SW, STE 2
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55902-3356
Practice Address - Country:US
Practice Address - Phone:507-252-5497
Practice Address - Fax:507-252-5497
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNMN LP 0653103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling