Provider Demographics
NPI:1568192169
Name:SMITH, EDMUND HARRY (SUDP)
Entity Type:Individual
Prefix:MR
First Name:EDMUND
Middle Name:HARRY
Last Name:SMITH
Suffix:
Gender:M
Credentials:SUDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16415 SMOKEY POINT BLVD
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:WA
Mailing Address - Zip Code:98223-8405
Mailing Address - Country:US
Mailing Address - Phone:425-533-2552
Mailing Address - Fax:425-366-8040
Practice Address - Street 1:16415 SMOKEY POINT BLVD
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:WA
Practice Address - Zip Code:98223-8405
Practice Address - Country:US
Practice Address - Phone:425-533-2552
Practice Address - Fax:425-366-8040
Is Sole Proprietor?:No
Enumeration Date:2022-06-15
Last Update Date:2022-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP00004421101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)