Basic Information
| Provider Information | |||||||||
| NPI: | 1619119377 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | PHILLIP | ||||||||
| MiddleName: | DEAN | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | LPC, NCC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1800 COMMUNITY | ||||||||
| Address2: | |||||||||
| City: | CLINTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 647358804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6608908186 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1450 E 10TH ST | ||||||||
| Address2: | |||||||||
| City: | ROLLA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 654013648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733647551 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2009 | ||||||||
| LastUpdateDate: | 11/14/2016 | ||||||||
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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 | 2016040160 | MO | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.