Healthcare Provider Details

I. General information

NPI: 1134543481
Provider Name (Legal Business Name): R. SMYLY ADDICTION CLINICAL SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2014
Last Update Date: 02/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

819 W GURLEY ST UNIT C
PRESCOTT AZ
86305-3626
US

IV. Provider business mailing address

819 W GURLEY ST UNIT C
PRESCOTT AZ
86305-3626
US

V. Phone/Fax

Practice location:
  • Phone: 928-671-1443
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: MATT LUCHINI
Title or Position: ACCOUNT MANAGER
Credential:
Phone: 928-533-4220