Basic Information
Provider Information | |||||||||
NPI: | 1104306034 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SMITH | ||||||||
FirstName: | SAMANTHA | ||||||||
MiddleName: | JADE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 895 CLEAR BRANCH RD | ||||||||
Address2: |   | ||||||||
City: | FARMERVILLE | ||||||||
State: | LA | ||||||||
PostalCode: | 712415043 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3182358769 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 801 N 31ST ST STE 1 | ||||||||
Address2: |   | ||||||||
City: | MONROE | ||||||||
State: | LA | ||||||||
PostalCode: | 712013959 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3187377794 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/20/2018 | ||||||||
LastUpdateDate: | 09/28/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X |   |   | N |   | Other Service Providers | Case Manager/Care Coordinator |   | 101YP2500X |   |   | Y |   | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.