Provider Demographics
NPI:1275804494
Name:SMITH, WAYMON GLEN (RAC)
Entity Type:Individual
Prefix:
First Name:WAYMON
Middle Name:GLEN
Last Name:SMITH
Suffix:
Gender:M
Credentials:RAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5159 HIGHWAY 4 E
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:LA
Mailing Address - Zip Code:71418-3580
Mailing Address - Country:US
Mailing Address - Phone:318-649-3625
Mailing Address - Fax:318-649-5731
Practice Address - Street 1:5159 HIGHWAY 4 E
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:LA
Practice Address - Zip Code:71418-3580
Practice Address - Country:US
Practice Address - Phone:318-649-3625
Practice Address - Fax:318-649-5731
Is Sole Proprietor?:No
Enumeration Date:2012-01-19
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARAC# 1371101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)