Provider Demographics
NPI:1215192596
Name:SMITH, WAYNE
Entity Type:Individual
Prefix:MR
First Name:WAYNE
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 S MINNESOTA AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57104-4871
Mailing Address - Country:US
Mailing Address - Phone:605-334-7713
Mailing Address - Fax:605-334-5348
Practice Address - Street 1:625 S MINNESOTA AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57104-4871
Practice Address - Country:US
Practice Address - Phone:605-334-7713
Practice Address - Fax:605-334-5348
Is Sole Proprietor?:No
Enumeration Date:2008-07-25
Last Update Date:2008-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDINTERN101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health