Provider Demographics
NPI:1386980928
Name:SMITH, LISA ANNETTE (BS IN IECE)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:ANNETTE
Last Name:SMITH
Suffix:
Gender:F
Credentials:BS IN IECE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1633 MURPHY RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:STRUNK
Mailing Address - State:KY
Mailing Address - Zip Code:42649-9358
Mailing Address - Country:US
Mailing Address - Phone:606-354-3818
Mailing Address - Fax:
Practice Address - Street 1:1633 MURPHY RIDGE RD
Practice Address - Street 2:
Practice Address - City:STRUNK
Practice Address - State:KY
Practice Address - Zip Code:42649-9358
Practice Address - Country:US
Practice Address - Phone:606-354-3818
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-01
Last Update Date:2013-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY000071339222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist