Provider Demographics
NPI:1548892821
Name:SMITH, EDWARD MICHAEL (LPC-IT)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:MICHAEL
Last Name:SMITH
Suffix:
Gender:M
Credentials:LPC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W350S1401 WATERVILLE RD
Mailing Address - Street 2:
Mailing Address - City:DOUSMAN
Mailing Address - State:WI
Mailing Address - Zip Code:53118-9020
Mailing Address - Country:US
Mailing Address - Phone:920-253-1862
Mailing Address - Fax:
Practice Address - Street 1:W350S1401 WATERVILLE RD
Practice Address - Street 2:
Practice Address - City:DOUSMAN
Practice Address - State:WI
Practice Address - Zip Code:53118-9020
Practice Address - Country:US
Practice Address - Phone:920-253-1862
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-05
Last Update Date:2020-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI265001101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100060402Medicaid
WI1114196854Medicaid