Provider Demographics
NPI:1194963629
Name:SMITH, MARY ELLEN (LMT)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ELLEN
Last Name:SMITH
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 1 BOX 108
Mailing Address - Street 2:
Mailing Address - City:FRAMETOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26623-9740
Mailing Address - Country:US
Mailing Address - Phone:304-364-5571
Mailing Address - Fax:
Practice Address - Street 1:847 STATE ST
Practice Address - Street 2:
Practice Address - City:GASSAWAY
Practice Address - State:WV
Practice Address - Zip Code:26624-9303
Practice Address - Country:US
Practice Address - Phone:304-364-8113
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-21
Last Update Date:2011-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2008-2502172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker