=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619529690
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALYSIA MARY KATHREN SMITH LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/10/2019
-----------------------------------------------------
Last Update Date | 05/10/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4404 WIS-70
-----------------------------------------------------
City | WEBSTER
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54893
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-349-8554
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | N11499 MCCLAIN LAKE RD
-----------------------------------------------------
City | TREGO
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54888-9142
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-416-1451
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 4292
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------