Provider Demographics
NPI:1114221207
Name:SMITH, DAVID WAYNE (LCSW)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:WAYNE
Last Name:SMITH
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:MR
Other - First Name:DAVID
Other - Middle Name:WAYNE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:107 ROGER DR
Mailing Address - Street 2:
Mailing Address - City:COLLINSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62234-5814
Mailing Address - Country:US
Mailing Address - Phone:618-792-1482
Mailing Address - Fax:
Practice Address - Street 1:10010 KENNERLY RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-2106
Practice Address - Country:US
Practice Address - Phone:314-525-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-04
Last Update Date:2019-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008035911101Y00000X
IL149.0047941041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor