Provider Demographics
NPI:1962547422
Name:SMITH-SHULL, JOHNNIE L (LICSW)
Entity type:Individual
Prefix:
First Name:JOHNNIE
Middle Name:L
Last Name:SMITH-SHULL
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:85 MECHANIC ST STE 3B-1
Mailing Address - Street 2:DARTMOUTH HITCHCOCK - PSYCHIATRY
Mailing Address - City:LEBANON
Mailing Address - State:NH
Mailing Address - Zip Code:03766-1537
Mailing Address - Country:US
Mailing Address - Phone:603-653-1732
Mailing Address - Fax:
Practice Address - Street 1:85 MECHANIC ST STE 3B-1
Practice Address - Street 2:DARTMOUTH HITCHCOCK - PSYCHIATRY
Practice Address - City:LEBANON
Practice Address - State:NH
Practice Address - Zip Code:03766-1537
Practice Address - Country:US
Practice Address - Phone:603-653-1732
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2016-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW000059241041C0700X
NH15131041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAGAB39738Medicare PIN
WAP99372Medicare UPIN