Provider Demographics
NPI:1790265197
Name:SMITH, DOMINIC (LPC)
Entity Type:Individual
Prefix:
First Name:DOMINIC
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2627 REDWING RD STE 235
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80526-6352
Mailing Address - Country:US
Mailing Address - Phone:970-658-7121
Mailing Address - Fax:
Practice Address - Street 1:2627 REDWING RD STE 235
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80526-6352
Practice Address - Country:US
Practice Address - Phone:970-658-7121
Practice Address - Fax:720-649-4951
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-16
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0014731101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty