Provider Demographics
NPI:1245768456
Name:SMITH, NICHOLAS ZANE (EDS)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:ZANE
Last Name:SMITH
Suffix:
Gender:M
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1190 CHAMBERS RD APT 210C
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43212-1724
Mailing Address - Country:US
Mailing Address - Phone:661-912-7595
Mailing Address - Fax:
Practice Address - Street 1:124 OHIO AVE
Practice Address - Street 2:
Practice Address - City:TIFFIN
Practice Address - State:OH
Practice Address - Zip Code:44883-1764
Practice Address - Country:US
Practice Address - Phone:419-455-9107
Practice Address - Fax:419-448-5221
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-01
Last Update Date:2017-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH3256742103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool