Provider Demographics
NPI:1477095628
Name:SMITH, SCOTT (MA, LICDC-CS)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:MA, LICDC-CS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1864 SUMMERCHASE RD NE
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44721-3815
Mailing Address - Country:US
Mailing Address - Phone:330-323-1374
Mailing Address - Fax:
Practice Address - Street 1:55 ARCH ST STE 3A
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44304-1447
Practice Address - Country:US
Practice Address - Phone:330-375-3584
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-04
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH02-1151101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1477095628Medicaid