Healthcare Provider Details

I. General information

NPI: 1699047639
Provider Name (Legal Business Name): MELISSA J. SMITH LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2012
Last Update Date: 02/10/2020
Certification Date: 02/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5608 ZUNI RD SE
ALBUQUERQUE NM
87108-2926
US

IV. Provider business mailing address

5608 ZUNI RD SE
ALBUQUERQUE NM
87108-2926
US

V. Phone/Fax

Practice location:
  • Phone: 505-262-6597
  • Fax: 505-265-7074
Mailing address:
  • Phone: 505-262-6597
  • Fax: 505-265-7074

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCSA0152111
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC-10954
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: