Basic Information
Provider Information
NPI: 1033557475
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: SMITH
FirstName: SUMMER
MiddleName: R
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 602 N WALTON BLVD
Address2:  
City: BENTONVILLE
State: AR
PostalCode: 727124576
CountryCode: US
TelephoneNumber: 4794641060
FaxNumber:  
Practice Location
Address1: 1200 W WALNUT ST
Address2: STE 3100
City: ROGERS
State: AR
PostalCode: 727563521
CountryCode: US
TelephoneNumber: 4796319996
FaxNumber:  
Other Information
ProviderEnumerationDate: 06/07/2013
LastUpdateDate: 06/07/2013
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
101Y00000X  Y Behavioral Health & Social Service ProvidersCounselor 

No ID Information.


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