Provider Demographics
NPI:1770258022
Name:SMITH, LISA ANN (TCADC)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:ANN
Last Name:SMITH
Suffix:
Gender:F
Credentials:TCADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3625 UTICA RIDGE RD STE F
Mailing Address - Street 2:
Mailing Address - City:BETTENDORF
Mailing Address - State:IA
Mailing Address - Zip Code:52722-1653
Mailing Address - Country:US
Mailing Address - Phone:563-359-6750
Mailing Address - Fax:
Practice Address - Street 1:3625 UTICA RIDGE RD STE F
Practice Address - Street 2:
Practice Address - City:BETTENDORF
Practice Address - State:IA
Practice Address - Zip Code:52722-1653
Practice Address - Country:US
Practice Address - Phone:563-359-6750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-10
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IATCADC101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)