Provider Demographics
NPI:1104392935
Name:SMITH, LOIS EILEEN (CDP)
Entity Type:Individual
Prefix:
First Name:LOIS
Middle Name:EILEEN
Last Name:SMITH
Suffix:
Gender:F
Credentials:CDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13242 ROAD 24 SW
Mailing Address - Street 2:
Mailing Address - City:MATTAWA
Mailing Address - State:WA
Mailing Address - Zip Code:99349-7205
Mailing Address - Country:US
Mailing Address - Phone:509-380-0042
Mailing Address - Fax:
Practice Address - Street 1:COYOTE RIDGE CORRECTION CENTER
Practice Address - Street 2:1301 NORTH EPHRATA AVE.
Practice Address - City:CONNELL
Practice Address - State:WA
Practice Address - Zip Code:99326
Practice Address - Country:US
Practice Address - Phone:509-543-5921
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-19
Last Update Date:2018-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP60080431101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty