Provider Demographics
NPI:1750546412
Name:SMITH, DERRICK WAYNE (MD, LMHCA, MA)
Entity type:Individual
Prefix:
First Name:DERRICK
Middle Name:WAYNE
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD, LMHCA, MA
Other - Prefix:
Other - First Name:D. WAYNE
Other - Middle Name:
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:507 BROMPTON LN
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-8208
Mailing Address - Country:US
Mailing Address - Phone:818-515-7991
Mailing Address - Fax:
Practice Address - Street 1:7500 BANNER WAY NE
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98115-4176
Practice Address - Country:US
Practice Address - Phone:206-427-4679
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-22
Last Update Date:2024-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 101YM0800X, 102L00000X
WAMD.615972662084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst