Provider Demographics
NPI:1124163324
Name:SMITH, WANDA BO (LCPC)
Entity type:Individual
Prefix:
First Name:WANDA
Middle Name:BO
Last Name:SMITH
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 20794
Mailing Address - Street 2:
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59104-0794
Mailing Address - Country:US
Mailing Address - Phone:406-690-1616
Mailing Address - Fax:406-294-2925
Practice Address - Street 1:710 GRAND AVE
Practice Address - Street 2:SUITE 6
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59101-5852
Practice Address - Country:US
Practice Address - Phone:406-690-1616
Practice Address - Fax:406-294-2925
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2009-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1113 LCPC101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT000741360OtherBCBS
MT0256165Medicaid