Provider Demographics
NPI:1477703585
Name:SMITH, MARK (LCSW)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:906 WELLS DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH DAYTONA
Mailing Address - State:FL
Mailing Address - Zip Code:32119-2551
Mailing Address - Country:US
Mailing Address - Phone:386-451-7364
Mailing Address - Fax:386-322-0812
Practice Address - Street 1:906 WELLS DR
Practice Address - Street 2:
Practice Address - City:SOUTH DAYTONA
Practice Address - State:FL
Practice Address - Zip Code:32119-2551
Practice Address - Country:US
Practice Address - Phone:386-451-7364
Practice Address - Fax:386-322-0812
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-25
Last Update Date:2008-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW69591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical