Healthcare Provider Details

I. General information

NPI: 1265002752
Provider Name (Legal Business Name): JEFFREY SMITH LCAS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/28/2021
Last Update Date: 06/28/2021
Certification Date: 06/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3826 BLAND RD
RALEIGH NC
27609-6239
US

IV. Provider business mailing address

3533 LIMBER LN
RALEIGH NC
27616-8981
US

V. Phone/Fax

Practice location:
  • Phone: 919-872-1441
  • Fax: 919-872-1455
Mailing address:
  • Phone: 919-426-4629
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number27088
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: