Healthcare Provider Details

I. General information

NPI: 1720242878
Provider Name (Legal Business Name): DEWAYNE SMITH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2008
Last Update Date: 07/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5861 WEST GULF BANK
HOUSTON TX
77088-4120
US

IV. Provider business mailing address

5861 WEST GULF BANK
HOUSTON TX
77088-4120
US

V. Phone/Fax

Practice location:
  • Phone: 281-405-9950
  • Fax:
Mailing address:
  • Phone: 281-405-9950
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: