Provider Demographics
NPI:1396998217
Name:SMITH, CAROL
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:
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 3720
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86003-3720
Mailing Address - Country:US
Mailing Address - Phone:928-526-0779
Mailing Address - Fax:928-526-0284
Practice Address - Street 1:15218 E FACKLY SPRINGS RD
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86401-8578
Practice Address - Country:US
Practice Address - Phone:928-303-6812
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-23
Last Update Date:2008-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ215253101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health