Provider Demographics
NPI:1861275778
Name:SMITH, CHANCE LAMAR
Entity type:Individual
Prefix:
First Name:CHANCE
Middle Name:LAMAR
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:987 E ASH ST STE A02
Mailing Address - Street 2:
Mailing Address - City:PIQUA
Mailing Address - State:OH
Mailing Address - Zip Code:45356-4133
Mailing Address - Country:US
Mailing Address - Phone:937-543-2275
Mailing Address - Fax:
Practice Address - Street 1:600 UNION BLVD
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:OH
Practice Address - Zip Code:45322-2121
Practice Address - Country:US
Practice Address - Phone:614-914-8781
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-15
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
OH186896171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health