Provider Demographics
NPI:1598196628
Name:SMITH, DARCELMARIE (MA,CADC,MISA)
Entity Type:Individual
Prefix:
First Name:DARCELMARIE
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:MA,CADC,MISA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:839 BROADWAY STE 104
Mailing Address - Street 2:
Mailing Address - City:GARY
Mailing Address - State:IN
Mailing Address - Zip Code:46402-2414
Mailing Address - Country:US
Mailing Address - Phone:219-882-4010
Mailing Address - Fax:
Practice Address - Street 1:839 BROADWAY STE 104
Practice Address - Street 2:
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46402-2414
Practice Address - Country:US
Practice Address - Phone:219-882-4010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-27
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL29680101YA0400X
IL101YA0400X
IL34964175T00000X
IL30643101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL30643OtherMISA
IL29680OtherCADC