Provider Demographics
NPI:1174566285
Name:SMITH, LAURIE S (PHD)
Entity type:Individual
Prefix:DR
First Name:LAURIE
Middle Name:S
Last Name:SMITH
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7617 MINERAL POINT RD
Mailing Address - Street 2:STE 300
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53717-1623
Mailing Address - Country:US
Mailing Address - Phone:608-833-9290
Mailing Address - Fax:608-833-9691
Practice Address - Street 1:7617 MINERAL POINT RD
Practice Address - Street 2:STE 300
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53717-1623
Practice Address - Country:US
Practice Address - Phone:608-833-9290
Practice Address - Fax:608-833-9691
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2011-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1632-057103TC2200X
WI1632-57103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI13344OtherDEAN CARE
WI39199900Medicaid
WI002584027OtherMEDICARE ID
WI13344OtherDEAN CARE