Provider Demographics
NPI:1629802079
Name:SMITH, EDNA KATHALEEN (CAC-AD)
Entity type:Individual
Prefix:
First Name:EDNA
Middle Name:KATHALEEN
Last Name:SMITH
Suffix:
Gender:F
Credentials:CAC-AD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 MONTROSE AVE
Mailing Address - Street 2:
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-4132
Mailing Address - Country:US
Mailing Address - Phone:443-722-6760
Mailing Address - Fax:
Practice Address - Street 1:4201 PRIMROSE AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21215-3305
Practice Address - Country:US
Practice Address - Phone:410-764-8560
Practice Address - Fax:410-764-9114
Is Sole Proprietor?:No
Enumeration Date:2024-08-28
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDAC2022101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)