Provider Demographics
NPI:1447685433
Name:SMITH, LONNIE RAE
Entity type:Individual
Prefix:
First Name:LONNIE
Middle Name:RAE
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:811 NE 112TH AVE STE 106
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98684-5115
Mailing Address - Country:US
Mailing Address - Phone:360-885-1057
Mailing Address - Fax:
Practice Address - Street 1:811 NE 112TH AVE STE 106
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98684-5115
Practice Address - Country:US
Practice Address - Phone:360-885-1057
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-09
Last Update Date:2013-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst