Provider Demographics
NPI:1174995138
Name:SMITH, LARRY LEE JR (MS)
Entity type:Individual
Prefix:MR
First Name:LARRY
Middle Name:LEE
Last Name:SMITH
Suffix:JR
Gender:M
Credentials:MS
Other - Prefix:MR
Other - First Name:LARRY
Other - Middle Name:LEE
Other - Last Name:SMITH
Other - Suffix:JR
Other - Last Name Type:Professional Name
Other - Credentials:MS
Mailing Address - Street 1:4827 RICE RD
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71119
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6015 HEARNE AVENUE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71108
Practice Address - Country:US
Practice Address - Phone:318-210-7307
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-29
Last Update Date:2024-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPLC9611101YP2500X, 101YM0800X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No171M00000XOther Service ProvidersCase Manager/Care Coordinator