Healthcare Provider Details

I. General information

NPI: 1265663504
Provider Name (Legal Business Name): SHARON SUZETTE SMITH-WILBORN LMSW, LISAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/04/2009
Last Update Date: 11/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4839 S DARROW DR G162
TEMPE AZ
85282-6684
US

IV. Provider business mailing address

4839 S DARROW DR G162
TEMPE AZ
85282-6684
US

V. Phone/Fax

Practice location:
  • Phone: 480-234-2404
  • Fax:
Mailing address:
  • Phone: 480-234-2404
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLISAC - 11665
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLMSW - 8441
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: