Provider Demographics
NPI:1902823891
Name:BURRY AND SMITH COUNSELING SERVICES INC.
Entity Type:Organization
Organization Name:BURRY AND SMITH COUNSELING SERVICES INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIM
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:M S,LCSW,LMFC
Authorized Official - Phone:260-436-5986
Mailing Address - Street 1:3266 MALLARD COVE LN
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-2883
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:260-436-5986
Practice Address - Street 1:3266 MALLARD COVE LN
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-2883
Practice Address - Country:US
Practice Address - Phone:260-436-5986
Practice Address - Fax:260-436-5986
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34002738A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN665040Medicare ID - Type UnspecifiedMENTAL HEALTH
IN160000Medicare ID - Type UnspecifiedMENTAL HEALTH