Provider Demographics
NPI:1942391263
Name:SMITH, DENISE SUSANNE (AA, LISAC)
Entity Type:Individual
Prefix:MS
First Name:DENISE
Middle Name:SUSANNE
Last Name:SMITH
Suffix:
Gender:F
Credentials:AA, LISAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:489 N ARROYO BLVD
Mailing Address - Street 2:
Mailing Address - City:NOGALES
Mailing Address - State:AZ
Mailing Address - Zip Code:85621-2644
Mailing Address - Country:US
Mailing Address - Phone:520-287-4713
Mailing Address - Fax:520-287-9794
Practice Address - Street 1:382 E WILCOX DR
Practice Address - Street 2:
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85635-2528
Practice Address - Country:US
Practice Address - Phone:520-459-2290
Practice Address - Fax:520-459-5372
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC1355101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ917536OtherAZ AHCCCS