Provider Demographics
NPI:1386705564
Name:SMITH, SALLY A (LISW ACP)
Entity type:Individual
Prefix:MS
First Name:SALLY
Middle Name:A
Last Name:SMITH
Suffix:
Gender:F
Credentials:LISW ACP
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 3327
Mailing Address - Street 2:
Mailing Address - City:FT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29708
Mailing Address - Country:US
Mailing Address - Phone:803-547-7099
Mailing Address - Fax:803-548-5383
Practice Address - Street 1:150 BW THOMAS DR
Practice Address - Street 2:STE 125
Practice Address - City:FT MILL
Practice Address - State:SC
Practice Address - Zip Code:29708
Practice Address - Country:US
Practice Address - Phone:803-547-7099
Practice Address - Fax:803-548-5383
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2013-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6244104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
S36140Medicare UPIN