Provider Demographics
NPI:1073866513
Name:SMITH, TONYA HALL (LPC, LMFT)
Entity type:Individual
Prefix:DR
First Name:TONYA
Middle Name:HALL
Last Name:SMITH
Suffix:
Gender:F
Credentials:LPC, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 MILL WOOD CIR
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39180-1344
Mailing Address - Country:US
Mailing Address - Phone:601-831-3304
Mailing Address - Fax:601-630-9842
Practice Address - Street 1:1905B MISSION 66 STE 4D
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39180-3711
Practice Address - Country:US
Practice Address - Phone:601-831-3304
Practice Address - Fax:601-456-4212
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-22
Last Update Date:2019-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA3869101YP2500X
MST0253106H00000X
MS1249101YP2500X
LA1070106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08574217Medicaid