Provider Demographics
NPI:1700397205
Name:SMITH, LESA A (MSW, CSW)
Entity Type:Individual
Prefix:
First Name:LESA
Middle Name:A
Last Name:SMITH
Suffix:
Gender:F
Credentials:MSW, CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:533 26TH ST STE 100
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84401-2459
Mailing Address - Country:US
Mailing Address - Phone:801-645-5455
Mailing Address - Fax:801-394-0394
Practice Address - Street 1:1050 E 3300 S
Practice Address - Street 2:
Practice Address - City:MILLCREEK
Practice Address - State:UT
Practice Address - Zip Code:84106-2184
Practice Address - Country:US
Practice Address - Phone:801-645-5455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-24
Last Update Date:2023-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
UT1128563035021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker