Provider Demographics
NPI:1265532956
Name:SMITH, LINDA A (LCSW)
Entity type:Individual
Prefix:
First Name:LINDA
Middle Name:A
Last Name:SMITH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2542 SE WELSH ST
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34984-5240
Mailing Address - Country:US
Mailing Address - Phone:772-871-5546
Mailing Address - Fax:772-871-5546
Practice Address - Street 1:2542 SE WELSH ST
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34984-5240
Practice Address - Country:US
Practice Address - Phone:772-871-5546
Practice Address - Fax:772-871-5546
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW77891041C0700X
NYR057520-011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01975415Medicaid
NYNE0811Medicare ID - Type Unspecified