Healthcare Provider Details

I. General information

NPI: 1063703221
Provider Name (Legal Business Name): CONSTANCE SALLY SMITH LADC, LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2011
Last Update Date: 05/27/2026
Certification Date: 05/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1230 EAGAN INDUSTRIAL RD SUITE 100
EAGAN MN
55121-1264
US

IV. Provider business mailing address

5515 45TH AVE S
MINNEAPOLIS MN
55417-2336
US

V. Phone/Fax

Practice location:
  • Phone: 612-454-2243
  • Fax: 651-454-2972
Mailing address:
  • Phone: 605-728-7343
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number302730
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: