Provider Demographics
NPI:1619529690
Name:SMITH, ALYSIA MARY KATHREN (LPC)
Entity Type:Individual
Prefix:
First Name:ALYSIA
Middle Name:MARY KATHREN
Last Name:SMITH
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N11499 MCCLAIN LAKE RD
Mailing Address - Street 2:
Mailing Address - City:TREGO
Mailing Address - State:WI
Mailing Address - Zip Code:54888-9142
Mailing Address - Country:US
Mailing Address - Phone:715-416-1451
Mailing Address - Fax:
Practice Address - Street 1:4404 WIS-70
Practice Address - Street 2:
Practice Address - City:WEBSTER
Practice Address - State:WI
Practice Address - Zip Code:54893
Practice Address - Country:US
Practice Address - Phone:715-349-8554
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-10
Last Update Date:2024-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4292101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health