Healthcare Provider Details

I. General information

NPI: 1700984804
Provider Name (Legal Business Name): LAURA LOUISE SMITH PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LAURA L. SMITH PH.D.

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 08/31/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 SAN RAFAEL AVE NE
ALBUQUERQUE NM
87122-1116
US

IV. Provider business mailing address

1 SAN RAFAEL AVE NE
ALBUQUERQUE NM
87122-1116
US

V. Phone/Fax

Practice location:
  • Phone: 505-823-1600
  • Fax: 505-823-1611
Mailing address:
  • Phone: 505-823-1600
  • Fax: 505-823-1611

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number757
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number757
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: