Provider Demographics
NPI:1215363221
Name:SMITH, GUY W (CSAC)
Entity Type:Individual
Prefix:
First Name:GUY
Middle Name:W
Last Name:SMITH
Suffix:
Gender:M
Credentials:CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8719 W DAPHNE ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53224-5340
Mailing Address - Country:US
Mailing Address - Phone:414-751-7618
Mailing Address - Fax:414-247-0816
Practice Address - Street 1:8719 W DAPHNE ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53224-5340
Practice Address - Country:US
Practice Address - Phone:414-751-7618
Practice Address - Fax:414-247-0816
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-23
Last Update Date:2013-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15456-132101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI15456-132OtherLICENSE