Provider Demographics
NPI:1942401500
Name:SMITH, CHARLES E (PHD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:E
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:PO BOX 84909
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-6209
Mailing Address - Country:US
Mailing Address - Phone:206-834-4100
Mailing Address - Fax:206-834-4131
Practice Address - Street 1:3670 STONE WAY N STE N271
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98103-8004
Practice Address - Country:US
Practice Address - Phone:206-834-4100
Practice Address - Fax:206-834-4131
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-30
Last Update Date:2018-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPY0521103TC0700X
WAPY60190567103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2065529Medicaid