Provider Demographics
NPI:1225450802
Name:SMITH, LINDA R (OFFICIAL AGENT)
Entity type:Individual
Prefix:
First Name:LINDA
Middle Name:R
Last Name:SMITH
Suffix:
Gender:
Credentials:OFFICIAL AGENT
Other - Prefix:
Other - First Name:LINDA
Other - Middle Name:R
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OFFICER AGENT
Mailing Address - Street 1:100 N BIGBY DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:TN
Mailing Address - Zip Code:38401-4704
Mailing Address - Country:US
Mailing Address - Phone:931-215-2182
Mailing Address - Fax:931-381-5363
Practice Address - Street 1:1324 TROTWOOD AVE STE 11
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:TN
Practice Address - Zip Code:38401-4750
Practice Address - Country:US
Practice Address - Phone:931-215-2182
Practice Address - Fax:931-381-5363
Is Sole Proprietor?:No
Enumeration Date:2014-01-15
Last Update Date:2025-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNTNMFT-1814101YM0800X
TNL000000036622101YM0800X
TN1000000012765252Y00000X, 252Y00000X
TN1000000012788253Z00000X
1000000012765171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes252Y00000XAgenciesEarly Intervention Provider Agency
No253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1962746842Medicaid
TNL000000036622OtherLEGACY LIFE CARE PROGRAMS-OUTPATIENT MENTAL HEALTH AGENCY LICENSE
TNQ0006613Medicaid
TNTN-Q006613Medicaid