Healthcare Provider Details

I. General information

NPI: 1255818985
Provider Name (Legal Business Name): WILLIE J SMITH LSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2018
Last Update Date: 03/02/2020
Certification Date: 03/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20600 CHAGRIN BLVD STE 320
SHAKER HEIGHTS OH
44122-5334
US

IV. Provider business mailing address

10100 ELIDA RD
DELPHOS OH
45833-9056
US

V. Phone/Fax

Practice location:
  • Phone: 216-295-7239
  • Fax: 216-295-7240
Mailing address:
  • Phone: 619-695-8010
  • Fax: 619-695-0004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberS0013048
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: