Provider Demographics
NPI:1598775595
Name:SMITH, GEORGE J WALKER (LCPC MHP)
Entity Type:Individual
Prefix:MR
First Name:GEORGE
Middle Name:J WALKER
Last Name:SMITH
Suffix:
Gender:M
Credentials:LCPC MHP
Other - Prefix:MR
Other - First Name:WALKER
Other - Middle Name:
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCPC MHP
Mailing Address - Street 1:210 N HIGGINS AVE STE 234
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59802-4497
Mailing Address - Country:US
Mailing Address - Phone:406-203-3064
Mailing Address - Fax:406-642-7037
Practice Address - Street 1:210 N HIGGINS AVE STE 234
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-4497
Practice Address - Country:US
Practice Address - Phone:406-203-3064
Practice Address - Fax:406-642-7037
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2016-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1044101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0287045Medicaid