=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366157620
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LISA KAY SMITH LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/20/2023
-----------------------------------------------------
Last Update Date | 01/20/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 603 UPLAND CREEK RD
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65201-6788
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-489-9619
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 603 UPLAND CREEK RD
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65201-6788
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-489-9619
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 000597
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------