Provider Demographics
NPI:1780911388
Name:SMITH, SHIRLEY J (LCSW)
Entity type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:J
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 1:1100 S MINT ST
Mailing Address - Street 2:STE 101
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28203-4049
Mailing Address - Country:US
Mailing Address - Phone:704-379-1850
Mailing Address - Fax:704-335-1395
Practice Address - Street 1:1100 S MINT ST
Practice Address - Street 2:STE 101
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-4049
Practice Address - Country:US
Practice Address - Phone:704-379-1850
Practice Address - Fax:704-335-1395
Is Sole Proprietor?:No
Enumeration Date:2009-11-03
Last Update Date:2010-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0011831041C0700X, 104100000X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6006205Medicaid
NC6006204Medicaid