Provider Demographics
NPI:1700130846
Name:SMITH, DESTA SUE (MA)
Entity Type:Individual
Prefix:
First Name:DESTA
Middle Name:SUE
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 1:301 W MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47302-3202
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1327 S 18TH ST
Practice Address - Street 2:
Practice Address - City:NEW CASTLE
Practice Address - State:IN
Practice Address - Zip Code:47362-2665
Practice Address - Country:US
Practice Address - Phone:765-593-0003
Practice Address - Fax:765-593-0032
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-27
Last Update Date:2012-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor