1790793099 NPI number — DR. LEANNE SUSAN SMITH PHD LMHC

Table of content: DR. LEANNE SUSAN SMITH PHD LMHC (NPI 1790793099)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790793099 NPI number — DR. LEANNE SUSAN SMITH PHD LMHC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMITH
Provider First Name:
LEANNE
Provider Middle Name:
SUSAN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHD LMHC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KIMPTON
Provider Other First Name:
LEANNE
Provider Other Middle Name:
SUSAN
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1790793099
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/04/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
104 SE 6TH ST
Provider Second Line Business Mailing Address:
STE 2
Provider Business Mailing Address City Name:
STUART
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34994
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
772-288-7370
Provider Business Mailing Address Fax Number:
772-288-7370

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
104 SE 6TH ST
Provider Second Line Business Practice Location Address:
STE 2
Provider Business Practice Location Address City Name:
STUART
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34994
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
772-288-7370
Provider Business Practice Location Address Fax Number:
772-288-7370
Provider Enumeration Date:
08/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  MH3950 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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