Provider Demographics
NPI:1477565422
Name:SMITH, MARY BOB (LPC)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:BOB
Last Name:SMITH
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6733
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75608-6733
Mailing Address - Country:US
Mailing Address - Phone:903-234-9556
Mailing Address - Fax:903-663-0378
Practice Address - Street 1:703 E MARSHALL AVE
Practice Address - Street 2:SUITE 4002
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75601-5500
Practice Address - Country:US
Practice Address - Phone:903-234-9556
Practice Address - Fax:903-663-0378
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10164101YP2500X
TX002974-036483106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
3318LCOtherBCBS TEXAS