Provider Demographics
NPI:1568901171
Name:SMITH, LYNETTE CORIE (PSYD)
Entity Type:Individual
Prefix:
First Name:LYNETTE
Middle Name:CORIE
Last Name:SMITH
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29398 RECOVERY WAY
Mailing Address - Street 2:
Mailing Address - City:JUNCTION CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97448-8442
Mailing Address - Country:US
Mailing Address - Phone:541-465-2776
Mailing Address - Fax:
Practice Address - Street 1:29398 RECOVERY WAY
Practice Address - Street 2:
Practice Address - City:JUNCTION CITY
Practice Address - State:OR
Practice Address - Zip Code:97448-8442
Practice Address - Country:US
Practice Address - Phone:541-465-2776
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-15
Last Update Date:2017-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2798103T00000X
IL071008723103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical