Provider Demographics
NPI:1265870323
Name:SMITH, VICKI LYNN (LCSW)
Entity type:Individual
Prefix:
First Name:VICKI
Middle Name:LYNN
Last Name:SMITH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3536 52ND ST
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53144-2662
Mailing Address - Country:US
Mailing Address - Phone:262-842-0538
Mailing Address - Fax:262-842-0539
Practice Address - Street 1:3536 52ND ST
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53144-2662
Practice Address - Country:US
Practice Address - Phone:262-842-0538
Practice Address - Fax:262-842-0539
Is Sole Proprietor?:No
Enumeration Date:2013-06-11
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7788-1231041C0700X
WI16457132101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100030733Medicaid