Basic Information
| Provider Information | |||||||||
| NPI: | 1740614692 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | DEBORAH | ||||||||
| MiddleName: | LOUISE | ||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 99 TAVERN RD | ||||||||
| Address2: | |||||||||
| City: | MARTINSBURG | ||||||||
| State: | WV | ||||||||
| PostalCode: | 254012890 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042637023 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 99 TAVERN RD | ||||||||
| Address2: | |||||||||
| City: | MARTINSBURG | ||||||||
| State: | WV | ||||||||
| PostalCode: | 254012890 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042637023 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2013 | ||||||||
| LastUpdateDate: | 10/23/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 2343 | WV | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101Y00000X | 0701002884 | VA | Y | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | 2343 | 01 | WV | WEST VIRGINIA BOARD OF EXAMINERS INCOUNSELING | OTHER | 0701002884 | 01 | VA | COMMONWEALTH OF VIRGINIA | OTHER |