Provider Demographics
NPI:1639063159
Name:SMITH, DESSIA LARICE
Entity type:Individual
Prefix:
First Name:DESSIA
Middle Name:LARICE
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1777 WINNERS CIR NE
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44721-4110
Mailing Address - Country:US
Mailing Address - Phone:330-809-8501
Mailing Address - Fax:
Practice Address - Street 1:1777 WINNERS CIR NE
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44721-4110
Practice Address - Country:US
Practice Address - Phone:330-809-8501
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-07
Last Update Date:2025-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X
OH251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health