Provider Demographics
NPI:1417497231
Name:WESLEY S SMOTHERMON
Entity Type:Organization
Organization Name:WESLEY S SMOTHERMON
Other - Org Name:WESLEY S SMOTHERMON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:TLMFT, CPT
Authorized Official - Prefix:
Authorized Official - First Name:WESLEY
Authorized Official - Middle Name:S
Authorized Official - Last Name:SMOTHERMON
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:316-648-9580
Mailing Address - Street 1:2801 W 15TH ST N
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67203-1833
Mailing Address - Country:US
Mailing Address - Phone:316-648-9580
Mailing Address - Fax:
Practice Address - Street 1:2801 W 15TH ST N
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67203-1833
Practice Address - Country:US
Practice Address - Phone:316-648-9580
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WESLEY S SMOTHERMON
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-02-27
Last Update Date:2017-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSKO1-14-3203106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS201142440AMedicaid