Healthcare Provider Details

I. General information

NPI: 1164846135
Provider Name (Legal Business Name): BRIDGES W. SMITH, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2014
Last Update Date: 02/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1241 VOLUNTEER PKWY STE 436
BRISTOL TN
37620-4659
US

IV. Provider business mailing address

1241 VOLUNTEER PKWY STE 436
BRISTOL TN
37620-4659
US

V. Phone/Fax

Practice location:
  • Phone: 423-990-2315
  • Fax: 423-990-2316
Mailing address:
  • Phone: 423-990-2315
  • Fax: 423-990-2316

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number11716
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number11716
License Number StateTN

VIII. Authorized Official

Name: MR. BRIDGES WADE SMITH III
Title or Position: SENIOR PSYCHOLOGICAL EXAMINER
Credential: M.S., LSPE
Phone: 423-990-2315