Provider Demographics
NPI:1811294648
Name:MAHAN SMITH, MARCIA (CASAC)
Entity type:Individual
Prefix:
First Name:MARCIA
Middle Name:
Last Name:MAHAN SMITH
Suffix:
Gender:F
Credentials:CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10470 QUEENS BLVD
Mailing Address - Street 2:SUITE 307
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-3638
Mailing Address - Country:US
Mailing Address - Phone:718-275-6010
Mailing Address - Fax:718-275-6062
Practice Address - Street 1:104 70 QUEENS BOULEVARD
Practice Address - Street 2:SUITE 307
Practice Address - City:QUEENS
Practice Address - State:NY
Practice Address - Zip Code:11375
Practice Address - Country:US
Practice Address - Phone:718-275-6010
Practice Address - Fax:718-275-6062
Is Sole Proprietor?:No
Enumeration Date:2011-02-14
Last Update Date:2017-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY25596101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)