Provider Demographics
NPI:1528461159
Name:SMITH-MCDANIEL, SADIE L (LCSW)
Entity type:Individual
Prefix:
First Name:SADIE
Middle Name:L
Last Name:SMITH-MCDANIEL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:SADIE
Other - Middle Name:L
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:101 E BOADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NM
Mailing Address - Zip Code:87413-5425
Mailing Address - Country:US
Mailing Address - Phone:505-330-8220
Mailing Address - Fax:
Practice Address - Street 1:101 E BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:NM
Practice Address - Zip Code:87413-6235
Practice Address - Country:US
Practice Address - Phone:505-330-8220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-26
Last Update Date:2021-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMC-09871101YS0200X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1041C0700XMedicaid
1649704925OtherNPI 2