Provider Demographics
NPI:1639355795
Name:SMITH, MARY E (CMHT, LPC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:E
Last Name:SMITH
Suffix:
Gender:F
Credentials:CMHT, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 839
Mailing Address - Street 2:
Mailing Address - City:CORINTH
Mailing Address - State:MS
Mailing Address - Zip Code:38835-0839
Mailing Address - Country:US
Mailing Address - Phone:662-286-2152
Mailing Address - Fax:662-286-8095
Practice Address - Street 1:2100 EAST CHAMBERS STREET
Practice Address - Street 2:
Practice Address - City:BOONEVILLE
Practice Address - State:MS
Practice Address - Zip Code:38829
Practice Address - Country:US
Practice Address - Phone:662-728-3174
Practice Address - Fax:662-286-8095
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-18
Last Update Date:2020-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2590101YP2500X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS2590OtherDEPARTMENT OF MENTAL HEALTH OF MISSISSIPPI