Healthcare Provider Details

I. General information

NPI: 1891316907
Provider Name (Legal Business Name): LORI A SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2020
Last Update Date: 05/12/2020
Certification Date: 05/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 N PLAZA DR
APACHE JUNCTION AZ
85120-5501
US

IV. Provider business mailing address

3717 S CHAPARRAL RD
APACHE JUNCTION AZ
85119-3608
US

V. Phone/Fax

Practice location:
  • Phone: 480-474-5542
  • Fax: 480-983-0896
Mailing address:
  • Phone: 480-200-0881
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC-18905
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: