Provider Demographics
NPI:1427288257
Name:MICKEY O. SMITH, LCSW,PA
Entity type:Organization
Organization Name:MICKEY O. SMITH, LCSW,PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LCSW, PA
Authorized Official - Prefix:
Authorized Official - First Name:MICKEY
Authorized Official - Middle Name:ORB
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, PA
Authorized Official - Phone:254-526-7272
Mailing Address - Street 1:1711 E CENTRAL TEXAS EXPY
Mailing Address - Street 2:SUITE 103
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76541-9166
Mailing Address - Country:US
Mailing Address - Phone:254-526-7272
Mailing Address - Fax:254-526-3949
Practice Address - Street 1:1711 E CENTRAL TEXAS EXPY
Practice Address - Street 2:SUITE 103
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76541-9166
Practice Address - Country:US
Practice Address - Phone:254-526-7272
Practice Address - Fax:254-526-3949
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-14
Last Update Date:2009-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX249601041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX184183504Medicaid