Provider Demographics
NPI:1851353759
Name:SMITH, BETTY JO (LPC CACIII)
Entity Type:Individual
Prefix:
First Name:BETTY JO
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:LPC CACIII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1148
Mailing Address - Street 2:
Mailing Address - City:MONUMENT
Mailing Address - State:CO
Mailing Address - Zip Code:80132-1148
Mailing Address - Country:US
Mailing Address - Phone:719-487-1102
Mailing Address - Fax:719-488-8103
Practice Address - Street 1:325 SECOND ST
Practice Address - Street 2:
Practice Address - City:MONUMENT
Practice Address - State:CO
Practice Address - Zip Code:80132-7935
Practice Address - Country:US
Practice Address - Phone:719-487-1102
Practice Address - Fax:719-488-8103
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-05
Last Update Date:2011-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3528101YA0400X
CO2589101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO082770Medicaid