Provider Demographics
NPI:1992005037
Name:SMITH, JUSTIN WILLIAM
Entity Type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:WILLIAM
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1355 E. MAIN
Mailing Address - Street 2:
Mailing Address - City:BATESVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72501
Mailing Address - Country:US
Mailing Address - Phone:870-793-8919
Mailing Address - Fax:
Practice Address - Street 1:1355 E. MAIN
Practice Address - Street 2:
Practice Address - City:BATESVILLE
Practice Address - State:AR
Practice Address - Zip Code:72501
Practice Address - Country:US
Practice Address - Phone:870-793-8919
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-22
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR922032356171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator