Provider Demographics
NPI:1093792392
Name:SMITH, RAPHAEL G (PSY D, HSPP)
Entity Type:Individual
Prefix:
First Name:RAPHAEL
Middle Name:G
Last Name:SMITH
Suffix:
Gender:M
Credentials:PSY D, HSPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4044 CENTRAL ST
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64111-2228
Mailing Address - Country:US
Mailing Address - Phone:816-960-4525
Mailing Address - Fax:
Practice Address - Street 1:4044 CENTRAL ST
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64111-2228
Practice Address - Country:US
Practice Address - Phone:816-960-4525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-28
Last Update Date:2010-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20041042A103TC0700X
MO2009038103103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN343420OtherMHN
IN000000188733OtherANTHEM BLUE CROSS
IN200095120Medicaid
IN444530VMedicare PIN