Provider Demographics
NPI:1811369820
Name:SMART, MICHAEL (LCSW)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:SMART
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 E LAHARPE ST
Mailing Address - Street 2:
Mailing Address - City:KIRKSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63501-4520
Mailing Address - Country:US
Mailing Address - Phone:660-665-1962
Mailing Address - Fax:660-665-3989
Practice Address - Street 1:428 S 36TH ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301-5924
Practice Address - Country:US
Practice Address - Phone:217-224-6300
Practice Address - Fax:217-224-4329
Is Sole Proprietor?:No
Enumeration Date:2015-10-29
Last Update Date:2015-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0047611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical