Provider Demographics
NPI:1174165195
Name:SMITH, SALLY NISSA (LSW)
Entity type:Individual
Prefix:
First Name:SALLY
Middle Name:NISSA
Last Name:SMITH
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3939 WOODGATE CT
Mailing Address - Street 2:
Mailing Address - City:ERLANGER
Mailing Address - State:KY
Mailing Address - Zip Code:41018-2923
Mailing Address - Country:US
Mailing Address - Phone:513-503-7544
Mailing Address - Fax:
Practice Address - Street 1:8140 DREAM ST STE D
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:KY
Practice Address - Zip Code:41042-7532
Practice Address - Country:US
Practice Address - Phone:513-503-7544
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-10
Last Update Date:2019-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY254374104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker