Provider Demographics
NPI:1386212413
Name:SMITH, ANGELA R (LPC-IT)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:R
Last Name:SMITH
Suffix:
Gender:F
Credentials:LPC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1918 PROSPECT ST
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54603-2070
Mailing Address - Country:US
Mailing Address - Phone:608-317-2425
Mailing Address - Fax:
Practice Address - Street 1:115 5TH AVE S STE 507
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-4018
Practice Address - Country:US
Practice Address - Phone:608-797-5679
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-15
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4986-226101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty