Provider Demographics
NPI:1518988203
Name:SMITH, LARRY WAYNE (LMHC)
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:WAYNE
Last Name:SMITH
Suffix:
Gender:M
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 N SHORTRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-8906
Mailing Address - Country:US
Mailing Address - Phone:317-644-9900
Mailing Address - Fax:
Practice Address - Street 1:141 N SHORTRIDGE RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46219-8906
Practice Address - Country:US
Practice Address - Phone:317-644-9900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2016-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39000511A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201359450Medicaid