Provider Demographics
NPI:1730298514
Name:SMITH, LISA J (LCSWR, LISW-CP)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:J
Last Name:SMITH
Suffix:
Gender:F
Credentials:LCSWR, LISW-CP
Other - Prefix:MS
Other - First Name:LISA
Other - Middle Name:J
Other - Last Name:HOWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:974 PERIWINKLE PL
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29577-5269
Mailing Address - Country:US
Mailing Address - Phone:843-712-1979
Mailing Address - Fax:
Practice Address - Street 1:901 N KINGS HWY
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29577-3722
Practice Address - Country:US
Practice Address - Phone:843-448-4820
Practice Address - Fax:843-448-9875
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2017-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC98751041C0700X
NY0699141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY618200OtherMVP MOHAWK VALLEY PLAN
NY618200OtherMVP MOHAWK VALLEY PLAN
NYDD2097Medicare ID - Type Unspecified