Provider Demographics
NPI:1548465453
Name:SMITH, PAMELA D (MSW, LCSW)
Entity type:Individual
Prefix:MS
First Name:PAMELA
Middle Name:D
Last Name:SMITH
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8649 GUM RD
Mailing Address - Street 2:
Mailing Address - City:CARTHAGE
Mailing Address - State:MO
Mailing Address - Zip Code:64836-8509
Mailing Address - Country:US
Mailing Address - Phone:417-388-1351
Mailing Address - Fax:
Practice Address - Street 1:2405 FAIRLAWN DR
Practice Address - Street 2:
Practice Address - City:CARTHAGE
Practice Address - State:MO
Practice Address - Zip Code:64836-3517
Practice Address - Country:US
Practice Address - Phone:417-359-8093
Practice Address - Fax:417-359-8094
Is Sole Proprietor?:No
Enumeration Date:2007-06-19
Last Update Date:2010-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20050255511041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO497241901Medicaid