Provider Demographics
NPI:1104285733
Name:SMITH, LISA A (LPC)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:A
Last Name:SMITH
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 STREET A STE C
Mailing Address - Street 2:
Mailing Address - City:PICAYUNE
Mailing Address - State:MS
Mailing Address - Zip Code:39466-6303
Mailing Address - Country:US
Mailing Address - Phone:601-569-5311
Mailing Address - Fax:
Practice Address - Street 1:120 STREET A STE C
Practice Address - Street 2:
Practice Address - City:PICAYUNE
Practice Address - State:MS
Practice Address - Zip Code:39466-6303
Practice Address - Country:US
Practice Address - Phone:601-569-5311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-10
Last Update Date:2019-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00018213Medicaid