Provider Demographics
NPI:1457352148
Name:SMITH, CHARLES (LMFT)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2006 EXECUTIVE PARK DR
Mailing Address - Street 2:
Mailing Address - City:OPELIKA
Mailing Address - State:AL
Mailing Address - Zip Code:36801-6074
Mailing Address - Country:US
Mailing Address - Phone:334-329-9930
Mailing Address - Fax:334-363-0740
Practice Address - Street 1:2206 EXECUTIVE PARK DR
Practice Address - Street 2:
Practice Address - City:OPELIKA
Practice Address - State:AL
Practice Address - Zip Code:36801-6062
Practice Address - Country:US
Practice Address - Phone:334-329-9930
Practice Address - Fax:334-363-0740
Is Sole Proprietor?:No
Enumeration Date:2005-08-03
Last Update Date:2016-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL259101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL259OtherLMFT
ALI652Medicare PIN