Provider Demographics
NPI:1619119377
Name:SMITH, PHILLIP DEAN (LPC, NCC)
Entity Type:Individual
Prefix:MR
First Name:PHILLIP
Middle Name:DEAN
Last Name:SMITH
Suffix:
Gender:M
Credentials:LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 COMMUNITY
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MO
Mailing Address - Zip Code:64735-8804
Mailing Address - Country:US
Mailing Address - Phone:660-890-8186
Mailing Address - Fax:
Practice Address - Street 1:1450 E 10TH ST
Practice Address - Street 2:
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401-3648
Practice Address - Country:US
Practice Address - Phone:573-364-7551
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-27
Last Update Date:2016-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016040160101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional