Provider Demographics
NPI:1427109131
Name:SMITH, SALLY M (LCSW-C)
Entity type:Individual
Prefix:
First Name:SALLY
Middle Name:M
Last Name:SMITH
Suffix:
Gender:F
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 CHERRY VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:REISTERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21136-3202
Mailing Address - Country:US
Mailing Address - Phone:410-517-0539
Mailing Address - Fax:
Practice Address - Street 1:5 BLOOMSBURY AVE
Practice Address - Street 2:
Practice Address - City:CATONSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21228-4641
Practice Address - Country:US
Practice Address - Phone:443-612-1402
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD023561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDJ438Medicare ID - Type Unspecified