Provider Demographics
NPI:1629329404
Name:SMITH, DESILYNN G (MS, LPC, ICS, CSAC,)
Entity type:Individual
Prefix:
First Name:DESILYNN
Middle Name:G
Last Name:SMITH
Suffix:
Gender:F
Credentials:MS, LPC, ICS, CSAC,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4201 N 27TH ST FL 7
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53216-1807
Mailing Address - Country:US
Mailing Address - Phone:414-554-5538
Mailing Address - Fax:414-485-7162
Practice Address - Street 1:4201 N 27TH ST FL 7
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53216-1807
Practice Address - Country:US
Practice Address - Phone:414-554-5538
Practice Address - Fax:414-485-7162
Is Sole Proprietor?:No
Enumeration Date:2012-09-20
Last Update Date:2024-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100026581Medicaid