Provider Demographics
NPI:1447244736
Name:SMITH, ROGER DALE (LCSW)
Entity type:Individual
Prefix:MR
First Name:ROGER
Middle Name:DALE
Last Name:SMITH
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 ROCKWOOD LN
Mailing Address - Street 2:
Mailing Address - City:HAZARD
Mailing Address - State:KY
Mailing Address - Zip Code:41701-9415
Mailing Address - Country:US
Mailing Address - Phone:606-436-5761
Mailing Address - Fax:606-436-5797
Practice Address - Street 1:115 ROCKWOOD LN
Practice Address - Street 2:
Practice Address - City:HAZARD
Practice Address - State:KY
Practice Address - Zip Code:41701-9415
Practice Address - Country:US
Practice Address - Phone:606-436-5761
Practice Address - Fax:606-436-5797
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY16791041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY0254670Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER