Basic Information
Provider Information | |||||||||
NPI: | 1639306756 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SMITH | ||||||||
FirstName: | THOMAS | ||||||||
MiddleName: | JR | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: | JR. | ||||||||
Credential: | AT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 790 ROBERTS DR | ||||||||
Address2: |   | ||||||||
City: | MONTICELLO | ||||||||
State: | AR | ||||||||
PostalCode: | 716555723 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8703679732 | ||||||||
FaxNumber: | 8704606133 | ||||||||
Practice Location | |||||||||
Address1: | 1802 HWY 82 WEST | ||||||||
Address2: |   | ||||||||
City: | CROSSETT | ||||||||
State: | AR | ||||||||
PostalCode: | 71635 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8703647248 | ||||||||
FaxNumber: | 8703642249 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/16/2009 | ||||||||
LastUpdateDate: | 07/17/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X |   |   | Y |   | Other Service Providers | Case Manager/Care Coordinator |   |
No ID Information.