Provider Demographics
NPI:1093986895
Name:SMITH, THERESE M (MAED- LISAC)
Entity Type:Individual
Prefix:MS
First Name:THERESE
Middle Name:M
Last Name:SMITH
Suffix:
Gender:F
Credentials:MAED- LISAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4129 E VAN BUREN ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85008-6939
Mailing Address - Country:US
Mailing Address - Phone:602-269-5331
Mailing Address - Fax:602-269-5331
Practice Address - Street 1:4129 E VAN BUREN ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85008-6939
Practice Address - Country:US
Practice Address - Phone:602-269-5331
Practice Address - Fax:602-269-5331
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-19
Last Update Date:2008-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC-10977101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)