Provider Demographics
NPI:1316190655
Name:SMITH, LANCE OBRIAN
Entity type:Individual
Prefix:
First Name:LANCE
Middle Name:OBRIAN
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 1:648 OVERHOUSE DRIVE
Mailing Address - Street 2:
Mailing Address - City:WINTERS
Mailing Address - State:CA
Mailing Address - Zip Code:95694-5063
Mailing Address - Country:US
Mailing Address - Phone:405-642-5758
Mailing Address - Fax:
Practice Address - Street 1:648 OVERHOUSE DR.
Practice Address - Street 2:
Practice Address - City:WINTERS
Practice Address - State:CA
Practice Address - Zip Code:95694-5063
Practice Address - Country:US
Practice Address - Phone:405-642-5758
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-30
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP1600X, 101YP2500X, 101YM0800X, 101YS0200X, 106H00000X
UT13638245101YA0400X
UT13638245-3902106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool