Provider Demographics
NPI:1679815484
Name:SMITH, SHANE TIMOTHY
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:TIMOTHY
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4629 CELIA WAY
Mailing Address - Street 2:APT 202
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98226-7475
Mailing Address - Country:US
Mailing Address - Phone:360-929-5964
Mailing Address - Fax:
Practice Address - Street 1:4629 CELIA WAY
Practice Address - Street 2:APT 202
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98226-7475
Practice Address - Country:US
Practice Address - Phone:360-929-5964
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-19
Last Update Date:2013-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor