Provider Demographics
NPI:1578692745
Name:SMITH, MARK W (MSW, LCSW)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:W
Last Name:SMITH
Suffix:
Gender:M
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6260 S LINDBERGH BLVD
Mailing Address - Street 2:STE. 103
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63123-7831
Mailing Address - Country:US
Mailing Address - Phone:314-845-9500
Mailing Address - Fax:314-845-6599
Practice Address - Street 1:6260 S LINDBERGH BLVD
Practice Address - Street 2:STE. 103
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63123-7831
Practice Address - Country:US
Practice Address - Phone:314-845-9500
Practice Address - Fax:314-845-6599
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOSWOO37371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical