Provider Demographics
NPI:1548497100
Name:SMITH, MARIAN L (PHD)
Entity type:Individual
Prefix:DR
First Name:MARIAN
Middle Name:L
Last Name:SMITH
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3101 CLUB MANOR DR STE A
Mailing Address - Street 2:
Mailing Address - City:MAUMELLE
Mailing Address - State:AR
Mailing Address - Zip Code:72113-6088
Mailing Address - Country:US
Mailing Address - Phone:501-271-8121
Mailing Address - Fax:866-573-0780
Practice Address - Street 1:3101 CLUB MANOR DR STE A
Practice Address - Street 2:
Practice Address - City:MAUMELLE
Practice Address - State:AR
Practice Address - Zip Code:72113-6088
Practice Address - Country:US
Practice Address - Phone:501-271-8121
Practice Address - Fax:866-573-0780
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-22
Last Update Date:2023-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY10836103TC0700X
MO2016032381103TC0700X
KS1923103TC0700X
KST-LP 1800103TC0700X
AR18-04P103TC0700X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200609050AMedicaid