Provider Demographics
NPI:1518152768
Name:SMITH, SALLY WILSON (MD)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:WILSON
Last Name:SMITH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:263 KING ST STE B
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29401-1420
Mailing Address - Country:US
Mailing Address - Phone:843-853-8007
Mailing Address - Fax:
Practice Address - Street 1:263 KING ST STE B
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29401-1420
Practice Address - Country:US
Practice Address - Phone:843-853-8007
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-11
Last Update Date:2007-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC167402084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry