Provider Demographics
NPI:1679239982
Name:SMITH, SARA (LMSW)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4405 PADRE BLVD
Mailing Address - Street 2:
Mailing Address - City:SOUTH PADRE ISLAND
Mailing Address - State:TX
Mailing Address - Zip Code:78597-7324
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4405 PADRE BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH PADRE ISLAND
Practice Address - State:TX
Practice Address - Zip Code:78597-7324
Practice Address - Country:US
Practice Address - Phone:844-827-1244
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-10
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX103723104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX41830196OtherDRIVER'S LICENSE