Healthcare Provider Details

I. General information

NPI: 1376401562
Provider Name (Legal Business Name): HEATHER SMITH PHD, LPC-MHSP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/14/2026
Last Update Date: 01/14/2026
Certification Date: 01/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3125 ILFORD RD NE
RIO RANCHO NM
87144-7615
US

IV. Provider business mailing address

3125 ILFORD RD NE
RIO RANCHO NM
87144-7615
US

V. Phone/Fax

Practice location:
  • Phone: 615-720-5608
  • Fax:
Mailing address:
  • Phone: 615-720-5608
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2623
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: