Provider Demographics
NPI:1508988908
Name:SMITH, MARK WILLIAM (LICSW)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:WILLIAM
Last Name:SMITH
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5939 PORTLAND AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55417-3127
Mailing Address - Country:US
Mailing Address - Phone:612-866-6100
Mailing Address - Fax:612-866-9379
Practice Address - Street 1:5939 PORTLAND AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55417-3127
Practice Address - Country:US
Practice Address - Phone:612-866-6100
Practice Address - Fax:612-866-9379
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN113721041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN102R8SMOtherBLUE CROSS BLUE SHIELD