Provider Demographics
NPI:1366791345
Name:SMITH, ANNETTE LOUISE (BS, SAC-IT)
Entity type:Individual
Prefix:
First Name:ANNETTE
Middle Name:LOUISE
Last Name:SMITH
Suffix:
Gender:F
Credentials:BS, SAC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 HALL AVE STE A
Mailing Address - Street 2:
Mailing Address - City:MARINETTE
Mailing Address - State:WI
Mailing Address - Zip Code:54143-1656
Mailing Address - Country:US
Mailing Address - Phone:715-732-7760
Mailing Address - Fax:715-732-7711
Practice Address - Street 1:2500 HALL AVE STE A
Practice Address - Street 2:
Practice Address - City:MARINETTE
Practice Address - State:WI
Practice Address - Zip Code:54143-1656
Practice Address - Country:US
Practice Address - Phone:715-732-7760
Practice Address - Fax:715-732-7711
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-05
Last Update Date:2012-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16658-130101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)