Provider Demographics
NPI:1972804474
Name:SMITH, MARIA L (PMHNP-BC, C-FNP, LPC)
Entity Type:Individual
Prefix:MS
First Name:MARIA
Middle Name:L
Last Name:SMITH
Suffix:
Gender:F
Credentials:PMHNP-BC, C-FNP, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 KENWOOD PL
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39202-2432
Mailing Address - Country:US
Mailing Address - Phone:601-951-0493
Mailing Address - Fax:
Practice Address - Street 1:103 SOUTHLAKE CIR
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MS
Practice Address - Zip Code:39046-5369
Practice Address - Country:US
Practice Address - Phone:601-824-0342
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-15
Last Update Date:2022-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1056101YP2500X
MS902088363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily