Provider Demographics
NPI:1740750934
Name:SMITH, ROBERT G (ACMHC)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:G
Last Name:SMITH
Suffix:
Gender:M
Credentials:ACMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4476 S 2300 E
Mailing Address - Street 2:
Mailing Address - City:HOLLADAY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-3612
Mailing Address - Country:US
Mailing Address - Phone:913-219-1733
Mailing Address - Fax:
Practice Address - Street 1:1425 S 700 E STE 102
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84105-2125
Practice Address - Country:US
Practice Address - Phone:385-313-0055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-29
Last Update Date:2018-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10387296-6009101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health