Provider Demographics
NPI:1104978089
Name:SMART, AMY M (MSW, LCSW, CACLLI)
Entity type:Individual
Prefix:MS
First Name:AMY
Middle Name:M
Last Name:SMART
Suffix:
Gender:F
Credentials:MSW, LCSW, CACLLI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1121 MERCURY DR
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:CO
Mailing Address - Zip Code:80026-8809
Mailing Address - Country:US
Mailing Address - Phone:303-665-8932
Mailing Address - Fax:
Practice Address - Street 1:500 COFFMAN ST STE 207
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-5445
Practice Address - Country:US
Practice Address - Phone:720-232-0406
Practice Address - Fax:720-232-0406
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2011-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO12781041C0700X
CO6624101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO45-3221940OtherEMPLOYER IDENTIFICATION NUMBER