Provider Demographics
NPI:1588761886
Name:SMITH, GORDON HILTON (BS)
Entity type:Individual
Prefix:MR
First Name:GORDON
Middle Name:HILTON
Last Name:SMITH
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4701 FAYETTEVILLE RD
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:NC
Mailing Address - Zip Code:28358-2697
Mailing Address - Country:US
Mailing Address - Phone:910-739-9755
Mailing Address - Fax:910-739-9788
Practice Address - Street 1:4701 FAYETTEVILLE RD
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:NC
Practice Address - Zip Code:28358-2697
Practice Address - Country:US
Practice Address - Phone:910-739-9755
Practice Address - Fax:910-739-9788
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2011-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC407101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6111783Medicaid
NC407OtherLCAS NUMBER