Provider Demographics
NPI:1942223524
Name:SMITH, WILLIAM RAPHAEL (PHD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:RAPHAEL
Last Name:SMITH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3130 N COUNTY ROAD 25A
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:OH
Mailing Address - Zip Code:45373-1337
Mailing Address - Country:US
Mailing Address - Phone:937-440-4000
Mailing Address - Fax:937-440-7882
Practice Address - Street 1:3130 N COUNTY ROAD 25A
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:OH
Practice Address - Zip Code:45373-1337
Practice Address - Country:US
Practice Address - Phone:937-440-4000
Practice Address - Fax:937-440-7882
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2007-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4246101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000302301OtherANTHEM
OH0787984Medicaid
OH0787984Medicaid