Provider Demographics
NPI:1194159145
Name:SMITH, ALEXA LYNN
Entity type:Individual
Prefix:
First Name:ALEXA
Middle Name:LYNN
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:89 ROUTE 130
Mailing Address - Street 2:
Mailing Address - City:FORESTDALE
Mailing Address - State:MA
Mailing Address - Zip Code:02644-1107
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:50 ALDRIN RD
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02360-4827
Practice Address - Country:US
Practice Address - Phone:508-830-0000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-27
Last Update Date:2013-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAS78684806101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor