Provider Demographics
NPI:1790961084
Name:SMITH, MISTY LANE (PCMHT)
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:LANE
Last Name:SMITH
Suffix:
Gender:F
Credentials:PCMHT
Other - Prefix:
Other - First Name:MISTY
Other - Middle Name:LANE
Other - Last Name:DICKERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSED
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 1:1213 MARIA LN
Practice Address - Street 2:
Practice Address - City:IUKA
Practice Address - State:MS
Practice Address - Zip Code:38852-1135
Practice Address - Country:US
Practice Address - Phone:662-423-3332
Practice Address - Fax:662-286-8095
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-16
Last Update Date:2018-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor