Provider Demographics
NPI:1811354426
Name:SMITH, LONNIE
Entity type:Individual
Prefix:
First Name:LONNIE
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1199 E RUSS RD
Mailing Address - Street 2:APT E-1
Mailing Address - City:GREENVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45331-3710
Mailing Address - Country:US
Mailing Address - Phone:937-474-5198
Mailing Address - Fax:
Practice Address - Street 1:1199 E. RUSS RD
Practice Address - Street 2:APT/ E-1
Practice Address - City:GREENVILLE
Practice Address - State:OH
Practice Address - Zip Code:45331
Practice Address - Country:US
Practice Address - Phone:937-474-5198
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-27
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker