Provider Demographics
NPI:1053449827
Name:SMITH, THERESA MARIA (LISW)
Entity type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:MARIA
Last Name:SMITH
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:TERRY
Other - Middle Name:
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LISW
Mailing Address - Street 1:32066 HANDFORD BLVD
Mailing Address - Street 2:
Mailing Address - City:AVON LAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44012-2936
Mailing Address - Country:US
Mailing Address - Phone:440-933-3123
Mailing Address - Fax:
Practice Address - Street 1:202 E BAGLEY RD
Practice Address - Street 2:
Practice Address - City:BEREA
Practice Address - State:OH
Practice Address - Zip Code:44017-2058
Practice Address - Country:US
Practice Address - Phone:440-260-8303
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI. 00043421041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical