Provider Demographics
NPI:1093732679
Name:SMITH, VIRGINIA A (MS, LPC)
Entity Type:Individual
Prefix:MRS
First Name:VIRGINIA
Middle Name:A
Last Name:SMITH
Suffix:
Gender:F
Credentials:MS, LPC
Other - Prefix:MISS
Other - First Name:VIRGINIA
Other - Middle Name:A
Other - Last Name:LECLAIR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS
Mailing Address - Street 1:520 58TH ST STE 200
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53140
Mailing Address - Country:US
Mailing Address - Phone:262-748-6048
Mailing Address - Fax:262-753-1922
Practice Address - Street 1:520 58TH ST. STE 200
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53140
Practice Address - Country:US
Practice Address - Phone:262-748-6048
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2023-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3146-125101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI9356249OtherPHCS
WI39662932002OtherBLUE CROSS/ BLUE SHIELD
WI306114372OtherUNITED BEHAVIORAL HEALTH
WI40932400Medicaid
WI861097264OtherHUMANA