Provider Demographics
NPI:1023223625
Name:SMITH, CRAIG WYATT (PHD)
Entity Type:Individual
Prefix:DR
First Name:CRAIG
Middle Name:WYATT
Last Name:SMITH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:806 LEGENDS VIEW DR
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:MO
Mailing Address - Zip Code:63025-2094
Mailing Address - Country:US
Mailing Address - Phone:636-549-3115
Mailing Address - Fax:
Practice Address - Street 1:3750 LINDELL BLVD
Practice Address - Street 2:113 MCGANNON HALL
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108-3412
Practice Address - Country:US
Practice Address - Phone:314-977-2507
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006033722106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist