Provider Demographics
NPI:1932452331
Name:SMITH, JOHN M (MSED, NCC, LMHC)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:M
Last Name:SMITH
Suffix:
Gender:M
Credentials:MSED, NCC, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3125 DOUGLAS AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50310-5310
Mailing Address - Country:US
Mailing Address - Phone:563-324-9309
Mailing Address - Fax:
Practice Address - Street 1:933 E 53RD ST
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52808
Practice Address - Country:US
Practice Address - Phone:563-324-9309
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-23
Last Update Date:2013-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001528101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health