Provider Demographics
NPI:1174852065
Name:CLEVENGER-SMITH, TELISA L (LMFTA)
Entity Type:Individual
Prefix:
First Name:TELISA
Middle Name:L
Last Name:CLEVENGER-SMITH
Suffix:
Gender:F
Credentials:LMFTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4534 WESTGATE BLVD
Mailing Address - Street 2:SUITE 112
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78745-1485
Mailing Address - Country:US
Mailing Address - Phone:512-963-7404
Mailing Address - Fax:
Practice Address - Street 1:4534 WESTGATE BLVD
Practice Address - Street 2:SUITE 112
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78745-1485
Practice Address - Country:US
Practice Address - Phone:512-963-7404
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-24
Last Update Date:2009-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX201468106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist