Provider Demographics
NPI:1912058629
Name:SMART, WANDA ELLEN (LPC)
Entity Type:Individual
Prefix:MS
First Name:WANDA
Middle Name:ELLEN
Last Name:SMART
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6402
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75608-6402
Mailing Address - Country:US
Mailing Address - Phone:903-758-2610
Mailing Address - Fax:903-758-3124
Practice Address - Street 1:501 PINE TREE RD STE A-0
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75604-4000
Practice Address - Country:US
Practice Address - Phone:903-758-2610
Practice Address - Fax:903-758-3124
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2021-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX13802101YM0800X, 101YP2500X
101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX13802OtherLICENSE TO PRACTICE
TX1130684-01Medicaid