Provider Demographics
NPI:1649694860
Name:SMITH, BRIDGES WADE III (MS, LSPE)
Entity type:Individual
Prefix:MR
First Name:BRIDGES
Middle Name:WADE
Last Name:SMITH
Suffix:III
Gender:M
Credentials:MS, LSPE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1241 VOLUNTEER PKWY
Mailing Address - Street 2:SUITE 436
Mailing Address - City:BRISTOL
Mailing Address - State:TN
Mailing Address - Zip Code:37620-4659
Mailing Address - Country:US
Mailing Address - Phone:423-990-2315
Mailing Address - Fax:423-990-2316
Practice Address - Street 1:1241 VOLUNTEER PKWY
Practice Address - Street 2:SUITE 436
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620-4659
Practice Address - Country:US
Practice Address - Phone:423-990-2315
Practice Address - Fax:423-990-2316
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-07
Last Update Date:2014-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN11716103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service