Provider Demographics
NPI:1699024216
Name:SMITH INMAN, LISA MARIE (MA LPCC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:SMITH INMAN
Suffix:
Gender:F
Credentials:MA LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:712 VISTA BLVD SUITE #172
Mailing Address - Street 2:
Mailing Address - City:WACONIA
Mailing Address - State:MN
Mailing Address - Zip Code:55387
Mailing Address - Country:US
Mailing Address - Phone:612-440-6882
Mailing Address - Fax:
Practice Address - Street 1:712 VISTA BLVD SUITE #172
Practice Address - Street 2:
Practice Address - City:WACONIA
Practice Address - State:MN
Practice Address - Zip Code:55387
Practice Address - Country:US
Practice Address - Phone:612-440-6882
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-29
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCC01162101YM0800X, 101Y00000X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor