Provider Demographics
NPI:1871642710
Name:SMITH, AUDREY LEE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:AUDREY
Middle Name:LEE
Last Name:SMITH
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:810 N 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85003-1318
Mailing Address - Country:US
Mailing Address - Phone:602-462-1115
Mailing Address - Fax:602-462-1119
Practice Address - Street 1:810 N 6TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85003-1318
Practice Address - Country:US
Practice Address - Phone:602-462-1115
Practice Address - Fax:602-462-1119
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3640103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical