Provider Demographics
NPI:1619320645
Name:SMITH, ALISA NICOLE (LISW)
Entity Type:Individual
Prefix:MRS
First Name:ALISA
Middle Name:NICOLE
Last Name:SMITH
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:MS
Other - First Name:ALISA
Other - Middle Name:NICOLE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:409 N. 4TH ST. P.O. BOX 12
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:IA
Mailing Address - Zip Code:52601
Mailing Address - Country:US
Mailing Address - Phone:319-208-9648
Mailing Address - Fax:319-208-8517
Practice Address - Street 1:409 N. 4TH ST.
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:IA
Practice Address - Zip Code:52601
Practice Address - Country:US
Practice Address - Phone:319-208-9648
Practice Address - Fax:319-208-8517
Is Sole Proprietor?:No
Enumeration Date:2016-07-14
Last Update Date:2019-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA082322104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker