Provider Demographics
NPI:1154995140
Name:SMITH, AUSTIN (LCSW)
Entity type:Individual
Prefix:
First Name:AUSTIN
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6412 N SNOWFLAKE DR
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86004-2636
Mailing Address - Country:US
Mailing Address - Phone:928-533-5982
Mailing Address - Fax:
Practice Address - Street 1:405 N BEAVER ST STE 10
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-4500
Practice Address - Country:US
Practice Address - Phone:928-286-7229
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-14
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLMSW-18770104100000X
AZLCSW-218001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker