Provider Demographics
NPI:1922015403
Name:SMITH, ROGER M (LCSW)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:M
Last Name:SMITH
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 1:14317 HICKORY DR
Mailing Address - Street 2:
Mailing Address - City:PONCHATOULA
Mailing Address - State:LA
Mailing Address - Zip Code:70454-6653
Mailing Address - Country:US
Mailing Address - Phone:985-974-8172
Mailing Address - Fax:985-386-0826
Practice Address - Street 1:14317 HICKORY DR.
Practice Address - Street 2:
Practice Address - City:PONCHATOULA
Practice Address - State:LA
Practice Address - Zip Code:70454-6653
Practice Address - Country:US
Practice Address - Phone:985-974-8172
Practice Address - Fax:985-386-0826
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2008-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA5099104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker