Provider Demographics
NPI:1245719178
Name:SMITH, COURTNEY (LAC)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 ASHBY ST APT D
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22305-2819
Mailing Address - Country:US
Mailing Address - Phone:571-405-1653
Mailing Address - Fax:
Practice Address - Street 1:3140 COMMONWEALTH AVE STE B
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22305-2712
Practice Address - Country:US
Practice Address - Phone:571-405-1653
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-10
Last Update Date:2018-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0121000887171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist