Provider Demographics
NPI:1376720441
Name:SMITH, RONALD GLENN (PHD)
Entity Type:Individual
Prefix:DR
First Name:RONALD
Middle Name:GLENN
Last Name:SMITH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2035 MESQUITE AVE
Mailing Address - Street 2:STE. C
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403-5894
Mailing Address - Country:US
Mailing Address - Phone:928-854-2373
Mailing Address - Fax:928-680-9811
Practice Address - Street 1:55 LAKE HAVASU AVE S
Practice Address - Street 2:STE. F-365
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-0938
Practice Address - Country:US
Practice Address - Phone:928-854-2373
Practice Address - Fax:928-680-9811
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-30
Last Update Date:2008-01-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ0954103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist