Provider Demographics
NPI:1598470759
Name:SMITH, LILLIAN BONNER (ALC)
Entity Type:Individual
Prefix:
First Name:LILLIAN
Middle Name:BONNER
Last Name:SMITH
Suffix:
Gender:F
Credentials:ALC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1435 BALCH RD UNIT 5105
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:AL
Mailing Address - Zip Code:35757-6375
Mailing Address - Country:US
Mailing Address - Phone:601-672-4675
Mailing Address - Fax:
Practice Address - Street 1:1435 BALCH RD UNIT 5105
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:AL
Practice Address - Zip Code:35757-6375
Practice Address - Country:US
Practice Address - Phone:601-672-4675
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-20
Last Update Date:2023-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty