Basic Information
| Provider Information | |||||||||
| NPI: | 1225328768 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | MA, LCPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2619 W. 6TH ST. | ||||||||
| Address2: | SUITE C | ||||||||
| City: | LAWRENCE | ||||||||
| State: | KS | ||||||||
| PostalCode: | 66049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6142638161 | ||||||||
| FaxNumber: | 6142638268 | ||||||||
| Practice Location | |||||||||
| Address1: | 2619 W. 6TH ST | ||||||||
| Address2: | SUITE C | ||||||||
| City: | LAWRENCE | ||||||||
| State: | KS | ||||||||
| PostalCode: | 66049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7858308299 | ||||||||
| FaxNumber: | 6142638268 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2011 | ||||||||
| LastUpdateDate: | 12/30/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | E.0800480 | OH | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.