Healthcare Provider Details

I. General information

NPI: 1871642710
Provider Name (Legal Business Name): AUDREY LEE SMITH PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

810 N 6TH AVE
PHOENIX AZ
85003-1318
US

IV. Provider business mailing address

810 N 6TH AVE
PHOENIX AZ
85003-1318
US

V. Phone/Fax

Practice location:
  • Phone: 602-462-1115
  • Fax: 602-462-1119
Mailing address:
  • Phone: 602-462-1115
  • Fax: 602-462-1119

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number3640
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: