Provider Demographics
NPI:1114337995
Name:SMITH, MARY ELISABETH (BA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELISABETH
Last Name:SMITH
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 N SUNNY SLOPE RD
Mailing Address - Street 2:SUITE #100
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-4806
Mailing Address - Country:US
Mailing Address - Phone:262-432-5660
Mailing Address - Fax:262-432-5666
Practice Address - Street 1:150 N SUNNY SLOPE RD
Practice Address - Street 2:SUITE #100
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-4806
Practice Address - Country:US
Practice Address - Phone:262-432-5660
Practice Address - Fax:262-432-5666
Is Sole Proprietor?:No
Enumeration Date:2014-05-02
Last Update Date:2014-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI83-140103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI83-140OtherBA LICENSE