Provider Demographics
NPI:1649704925
Name:SADIE L SMITH-MCDANIEL
Entity type:Organization
Organization Name:SADIE L SMITH-MCDANIEL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SADIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH-MCDANIEL
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:505-947-4384
Mailing Address - Street 1:101 E BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NM
Mailing Address - Zip Code:87413-6235
Mailing Address - Country:US
Mailing Address - Phone:505-330-8220
Mailing Address - Fax:
Practice Address - Street 1:101 E BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:NM
Practice Address - Zip Code:87413-6235
Practice Address - Country:US
Practice Address - Phone:505-330-8220
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SADIE L SMITH-MCDANIEL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-04-13
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251B00000X, 251S00000X, 101YM0800X
NMC-09871251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No251B00000XAgenciesCase ManagementGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM51331764Medicaid