Provider Demographics
NPI:1508456450
Name:SMITH, SALLY J (LISW-S)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:J
Last Name:SMITH
Suffix:
Gender:F
Credentials:LISW-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 S BRINKER AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43204-1911
Mailing Address - Country:US
Mailing Address - Phone:740-403-9562
Mailing Address - Fax:
Practice Address - Street 1:128 S BRINKER AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43204-1911
Practice Address - Country:US
Practice Address - Phone:740-403-9562
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-25
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.0007342-SUPV1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical