Provider Demographics
NPI:1700371689
Name:SMITH, GENEVERE ANN (LGSW)
Entity Type:Individual
Prefix:
First Name:GENEVERE
Middle Name:ANN
Last Name:SMITH
Suffix:
Gender:F
Credentials:LGSW
Other - Prefix:
Other - First Name:GENEVERE
Other - Middle Name:ANN
Other - Last Name:SMART
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LGSW
Mailing Address - Street 1:1900 SILVER LAKE RD NW STE 110
Mailing Address - Street 2:
Mailing Address - City:NEW BRIGHTON
Mailing Address - State:MN
Mailing Address - Zip Code:55112-1789
Mailing Address - Country:US
Mailing Address - Phone:651-628-9566
Mailing Address - Fax:951-628-0411
Practice Address - Street 1:13045 FALCON DR STE 100
Practice Address - Street 2:
Practice Address - City:BAXTER
Practice Address - State:MN
Practice Address - Zip Code:56425-4201
Practice Address - Country:US
Practice Address - Phone:218-829-9307
Practice Address - Fax:218-829-7649
Is Sole Proprietor?:No
Enumeration Date:2018-06-24
Last Update Date:2018-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health