Healthcare Provider Details

I. General information

NPI: 1114221207
Provider Name (Legal Business Name): DAVID WAYNE SMITH LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: DAVID WAYNE SMITH LCSW

II. Dates (important events)

Enumeration Date: 01/04/2011
Last Update Date: 11/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10010 KENNERLY RD
SAINT LOUIS MO
63128-2106
US

IV. Provider business mailing address

107 ROGER DR
COLLINSVILLE IL
62234-5814
US

V. Phone/Fax

Practice location:
  • Phone: 314-525-1000
  • Fax:
Mailing address:
  • Phone: 618-792-1482
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number2008035911
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.004794
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: