Provider Demographics
NPI:1912043415
Name:SMITH, JAMES R (MSW, LISW)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:R
Last Name:SMITH
Suffix:
Gender:M
Credentials:MSW, LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2871 HEINZ RD
Mailing Address - Street 2:STE 'B'
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52240-8196
Mailing Address - Country:US
Mailing Address - Phone:319-936-6248
Mailing Address - Fax:319-351-0070
Practice Address - Street 1:2871 HEINZ RD
Practice Address - Street 2:STE 'B'
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52240-8196
Practice Address - Country:US
Practice Address - Phone:319-936-6248
Practice Address - Fax:319-351-0070
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2013-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02512101Y00000X, 101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1912043415Medicaid
IA1962555003Medicaid