Basic Information
| Provider Information | |||||||||
| NPI: | 1073784898 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | |||||||||
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| Credential: | L.C.D.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2603 | ||||||||
| Address2: | HTN, CLIENT ACCOUNTING | ||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761132603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8175694396 | ||||||||
| FaxNumber: | 8175694517 | ||||||||
| Practice Location | |||||||||
| Address1: | 3840 HULEN ST | ||||||||
| Address2: | HTN, CLIENT ACCOUNTING | ||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761077277 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8175694396 | ||||||||
| FaxNumber: | 8175694517 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2008 | ||||||||
| LastUpdateDate: | 05/18/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 5881 | TX | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 8719BH | 01 | TX | BCBS | OTHER |