Provider Demographics
NPI:1902582273
Name:SMITH, LYNETTE ANNE (ADT 2477)
Entity Type:Individual
Prefix:
First Name:LYNETTE
Middle Name:ANNE
Last Name:SMITH
Suffix:
Gender:F
Credentials:ADT 2477
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3330 SAINT AMBROSE AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21215-6311
Mailing Address - Country:US
Mailing Address - Phone:202-985-9536
Mailing Address - Fax:
Practice Address - Street 1:3330 SAINT AMBROSE AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21215-6311
Practice Address - Country:US
Practice Address - Phone:202-985-9536
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-22
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD932018402101YA0400X
MD93-2018402251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty