Provider Demographics
NPI:1518925536
Name:SMITH, LISA A (MED)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:A
Last Name:SMITH
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1150 LOUISIANA AVE
Mailing Address - Street 2:SUITE 5B
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32789-2354
Mailing Address - Country:US
Mailing Address - Phone:407-629-6448
Mailing Address - Fax:407-629-6447
Practice Address - Street 1:1150 LOUISIANA AVE
Practice Address - Street 2:SUITE 5B
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32789-2354
Practice Address - Country:US
Practice Address - Phone:407-629-6448
Practice Address - Fax:407-629-6447
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL108101YM0800X
FL016106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist