Provider Demographics
NPI:1245530708
Name:SMITH, PENELOPE A (MA)
Entity type:Individual
Prefix:MS
First Name:PENELOPE
Middle Name:A
Last Name:SMITH
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10466 CHESTNUT RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:TN
Mailing Address - Zip Code:37352-5629
Mailing Address - Country:US
Mailing Address - Phone:931-307-8768
Mailing Address - Fax:931-759-5176
Practice Address - Street 1:10466 CHESTNUT RIDGE RD
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:TN
Practice Address - Zip Code:37352-5629
Practice Address - Country:US
Practice Address - Phone:931-307-8768
Practice Address - Fax:931-759-5176
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-29
Last Update Date:2010-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPE0000011688101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health