Provider Demographics
NPI:1710323886
Name:SMITH, MANDY (LCPC)
Entity Type:Individual
Prefix:MS
First Name:MANDY
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:816 OLMSTEAD RD
Mailing Address - Street 2:
Mailing Address - City:PIKESVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21208-4754
Mailing Address - Country:US
Mailing Address - Phone:443-470-5656
Mailing Address - Fax:443-470-8658
Practice Address - Street 1:405 ALLEGHENY AVE
Practice Address - Street 2:
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21204-4256
Practice Address - Country:US
Practice Address - Phone:443-470-5656
Practice Address - Fax:443-470-8658
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-16
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC1909101YA0400X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD645011300Medicaid