Provider Demographics
NPI:1730235755
Name:SMITH, CARLA RAE
Entity type:Individual
Prefix:MRS
First Name:CARLA
Middle Name:RAE
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CARLA
Other - Middle Name:RAE
Other - Last Name:LOOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 100
Mailing Address - Street 2:
Mailing Address - City:PENDER
Mailing Address - State:NE
Mailing Address - Zip Code:68047-0100
Mailing Address - Country:US
Mailing Address - Phone:402-385-4004
Mailing Address - Fax:
Practice Address - Street 1:100 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:PENDER
Practice Address - State:NE
Practice Address - Zip Code:68047-4507
Practice Address - Country:US
Practice Address - Phone:402-385-3083
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2020-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE16601041C0700X
IA03661104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker