Provider Demographics
NPI:1477350015
Name:SMITH, JOSEPH DERRELLE
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:DERRELLE
Last Name:SMITH
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14131 KARL ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68137-1505
Mailing Address - Country:US
Mailing Address - Phone:917-686-8384
Mailing Address - Fax:
Practice Address - Street 1:14131 KARL ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68137-1505
Practice Address - Country:US
Practice Address - Phone:917-686-8384
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-01
Last Update Date:2025-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE103TH0004X103TH0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth