Healthcare Provider Details

I. General information

NPI: 1205607751
Provider Name (Legal Business Name): ANDREW DOUGLAS SMITH LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2024
Last Update Date: 08/06/2024
Certification Date: 08/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28 E RAHN RD STE 217
KETTERING OH
45429-5461
US

IV. Provider business mailing address

7254 CHATEAUROUX DR APT B
CENTERVILLE OH
45459-5377
US

V. Phone/Fax

Practice location:
  • Phone: 828-450-4602
  • Fax:
Mailing address:
  • Phone: 828-450-4602
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberC.2406105
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: