Provider Demographics
NPI:1245888676
Name:SMITH, WILEY LIVINGSTON (LCMHCA)
Entity type:Individual
Prefix:
First Name:WILEY
Middle Name:LIVINGSTON
Last Name:SMITH
Suffix:
Gender:
Credentials:LCMHCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 W 1ST ST STE 410
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27104-4225
Mailing Address - Country:US
Mailing Address - Phone:336-716-7339
Mailing Address - Fax:
Practice Address - Street 1:403 SOUTH HAWTHORNE ROAD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27157-5008
Practice Address - Country:US
Practice Address - Phone:336-716-0855
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-28
Last Update Date:2025-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NC17670101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty