Provider Demographics
NPI:1033689278
Name:SMITH, ALISSA L (LMT)
Entity Type:Individual
Prefix:
First Name:ALISSA
Middle Name:L
Last Name:SMITH
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6440 E BROADWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85710-3504
Mailing Address - Country:US
Mailing Address - Phone:520-881-0827
Mailing Address - Fax:
Practice Address - Street 1:6440 E BROADWAY BLVD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85710-3504
Practice Address - Country:US
Practice Address - Phone:520-881-0827
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-30
Last Update Date:2018-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT-23753225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist