Provider Demographics
NPI:1659312973
Name:SMITH, THERESA FLYNN (MSW LCSW)
Entity Type:Individual
Prefix:MS
First Name:THERESA
Middle Name:FLYNN
Last Name:SMITH
Suffix:
Gender:F
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 1:517 TOMAHAWK AVE
Mailing Address - Street 2:
Mailing Address - City:BLACK MOUNTAIN
Mailing Address - State:NC
Mailing Address - Zip Code:28711-2861
Mailing Address - Country:US
Mailing Address - Phone:828-552-1390
Mailing Address - Fax:828-544-1201
Practice Address - Street 1:517 TOMAHAWK AVE
Practice Address - Street 2:
Practice Address - City:BLACK MOUNTAIN
Practice Address - State:NC
Practice Address - Zip Code:28711-2861
Practice Address - Country:US
Practice Address - Phone:828-552-1390
Practice Address - Fax:828-298-4870
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-09
Last Update Date:2019-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0017351041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1148FOtherBLUE CROSSAND BLUE SHIELD
NC6002201Medicaid