Provider Demographics
NPI:1558514505
Name:SMITH, LISA D
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:D
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2603 N ROLLING RD
Mailing Address - Street 2:SUITE 301
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21244-1975
Mailing Address - Country:US
Mailing Address - Phone:410-597-8788
Mailing Address - Fax:
Practice Address - Street 1:93 S MCCAIN DR
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21703-6007
Practice Address - Country:US
Practice Address - Phone:410-597-8788
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-03
Last Update Date:2008-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD06000320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD216211300Medicaid
MD216211300Medicaid