Provider Demographics
NPI:1255710570
Name:SMITH, LISA (LICDC, SAP, LPC)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:LICDC, SAP, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16908 WALDEN AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44128-1542
Mailing Address - Country:US
Mailing Address - Phone:216-246-2944
Mailing Address - Fax:
Practice Address - Street 1:4100 FRANKLIN BLVD
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44113-2842
Practice Address - Country:US
Practice Address - Phone:216-623-0959
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-19
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.2003026101YP2500X
261QM0801X
OHOCPC.1222405300000X
OH111024101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No405300000XOther Service ProvidersPrevention Professional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0206488Medicaid