MEDICARE: LISA M SMITH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	0710102358	VA

General Provider Information

NPI Number	:	1063132264
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA M SMITH

Provider Business Mailing Address
First Line	:	615 ELSINORE PL STE 200
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45202-1457
Country	:	US
Telephone Number	:	276-252-3700
Fax Number	:

Provider Business Practice Location Address
First Line	:	1836 VIRGINIA AVE
Second Line	:
City	:	MARTINSVILLE
State	:	VA
Zip	:	24112-8490
Country	:	US
Telephone Number	:	419-580-1305
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/30/2022
Last Update Date	:	08/30/2022

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Directions to “ LISA M SMITH ” Practice Location

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