Provider Demographics
NPI:1235485509
Name:SMITH, DANA LYN (MSW, MHP,LICSW, CMHS)
Entity Type:Individual
Prefix:
First Name:DANA
Middle Name:LYN
Last Name:SMITH
Suffix:
Gender:F
Credentials:MSW, MHP,LICSW, CMHS
Other - Prefix:
Other - First Name:DANA
Other - Middle Name:LYN
Other - Last Name:FRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW, LICSW, CMHS
Mailing Address - Street 1:714 E EDISON AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:SUNNYSIDE
Mailing Address - State:WA
Mailing Address - Zip Code:98944-2204
Mailing Address - Country:US
Mailing Address - Phone:509-515-0420
Mailing Address - Fax:509-515-0422
Practice Address - Street 1:714 E EDISON AVE
Practice Address - Street 2:SUITE B
Practice Address - City:SUNNYSIDE
Practice Address - State:WA
Practice Address - Zip Code:98944-2204
Practice Address - Country:US
Practice Address - Phone:509-515-0420
Practice Address - Fax:509-515-0422
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-24
Last Update Date:2017-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW000092501041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2038375Medicaid