Provider Demographics
NPI:1558526921
Name:SMITH, LISA M (MS)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:SMITH
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1244 E WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:WESTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43081-2547
Mailing Address - Country:US
Mailing Address - Phone:146-634-6005
Mailing Address - Fax:
Practice Address - Street 1:1244 E WALNUT ST
Practice Address - Street 2:
Practice Address - City:WESTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43081-2547
Practice Address - Country:US
Practice Address - Phone:146-634-6005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-24
Last Update Date:2018-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP-8849235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0094740Medicaid