Provider Demographics
NPI:1629464540
Name:SMITH, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 PULASKI CT
Mailing Address - Street 2:
Mailing Address - City:FORT LEONARD WOOD
Mailing Address - State:MO
Mailing Address - Zip Code:65473-1322
Mailing Address - Country:US
Mailing Address - Phone:573-774-5353
Mailing Address - Fax:573-774-2907
Practice Address - Street 1:1000 HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:WAYNESVILLE
Practice Address - State:MISSOURI
Practice Address - Zip Code:65583
Practice Address - Country:UM
Practice Address - Phone:573-774-2907
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-07
Last Update Date:2015-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015038855101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional